Cesar - Cardio & Hema

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DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.

COLLEGE OF NURSING
2nd Semester, S.Y. 2019-2020

Worksheet no. 2
Concept:
Alteration in
Cardiovascular &
Hematologic
System
Submitted by:
KATYANA ANTOINE D. CESAR
BSN – 2B
I. LABORATORY EXAMS
i. CARDIOMARKER ANALYSIS
A. ENZYME & ISOENZYME STUDIES
a.1. HYDROXYBUTYRIC DEHYDROGENASE
DEFINITION:
• In enzymology, 3-hydroxybutyrate dehydrogenase is an enzyme that catalyzes the chemical
reaction. 3-Hydroxybutyrate dehydrogenase (3-HBDH) enzyme, obtained from Rhodobacter
sphaeroides, is generally used for the quantification of ketone bodies, such as D-3-hydroxybutyrate
and acetoacetate.
PURPOSE:
• An enzyme that catalyzes the chemical reaction. This enzyme participates in the synthesis and
degradation of ketone bodies and the metabolism of butyric acid.
INDICATION:
• For the diagnosis of myocardial infarction.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
• Succinic semialdehyde dehydrogenase deficiency. Xyrem is contraindicated in patients with
succinic semialdehyde dehydrogenase deficiency. This is a rare disorder of inborn error of
metabolism variably characterized by mental retardation, hypotonia, and ataxia.
NORMAL VALUES:
• Normal. At 25 C = 68 to 135 U/L. At 30 C = 82 to 163 U/L. At 37 C = 96 to190 U/L.
PROCEDURE:
• Serum (7–10 mL, 1 mL minimum for individual test) obtained by venipuncture, using a red-top
tube (prechilled lavender-top tube for ANF).
• Avoid hemolysis.
• Food and fluids are not restricted. (Fasting sample is required for ANF.)
• Most cardiac enzymes must be retested 3 days in succession (eg, 1–2 hours for the first 12 hours
and then every 12 hours for 24 hours) to have clinical significance. Cardiac troponin concentrations
should be measured on serial blood samples collected at least 6 to 9 hours after the onset of
symptoms, before a patient is ruled in or ruled out for MI. If cardiac troponin assays are not
available, the best alternative is creatine kinase MB (CK-MB).
IMPLICATIONS OF ABNORMAL RESULTS:
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
• Apply pressure or a pressure dressing to the venipuncture site and monitor for bleeding or infection.
• Report all elevated enzyme levels to the physician immediately so that appropriate medical
interventions are not delayed.
• Evaluate outcomes and counsel the patient appropriately (eg, for newly diagnosed MI, consider the
need for lifestyle adjustment, rest, activity and diet changes, medications, work, and leisure
activity).• Further testing may be needed to monitor success of thrombolytic therapy for acute MIs.
a.2. ASPARTATE AMINOTRANSFERASE
DEFINITION:
• Aspartate aminotransferase (AST) is a transaminase enzyme that catalyzes the conversion of
aspartate and alpha-ketoglutarate to oxaloacetate and glutamate.
PURPOSE:
• Doctors commonly use the AST test to check for liver conditions, such as hepatitis. It’s usually
measured together with alanine aminotransferase (ALT) According to liver specialists, abnormal
ALT results are more likely related to liver injury than abnormal AST results. In fact, if AST levels
are abnormal and ALT levels are normal, the problem is much more likely due to a heart condition
or muscle problem rather than the liver. In some cases, the AST-to-ALT ratio may help your doctor
diagnose certain liver diseases.
INDICATIONS:
• High levels of AST in the blood may indicate hepatitis, cirrhosis, mononucleosis, or other liver
diseases. High AST levels can also indicate heart problems or pancreatitis. If your results are not in
the normal range, it doesn't necessarily mean that you have a medical condition needing treatment.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 The only precaution needed is to clean the venipuncture site with alcohol.
 Hemolysis falsely increases AST values.
 Hemodialysis falsely decreases AST values.
NORMAL VALUES:
 Normal ranges for the AST are laboratory-specific, but can range from 3–45 units/L (units per liter).
PROCEDURE:
• The AST test is performed on a blood sample. A healthcare provider usually takes the sample from
a vein in your arm or hand using a small needle. They collect the blood in a tube and send it to a lab
for analysis. Your doctor will inform you about your results when they become available.
IMPLICATIONS OF ABNORMAL RESULTS:
• A small amount of AST is typically in your bloodstream. Higher-than-normal amounts of this
enzyme in your blood may be a sign of a health problem. Abnormal levels can be associated with
liver injury. AST levels increase when there's damage to the tissues and cells where the enzyme is
found.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Teaching the Patient What to Expect
 Inform the patient this test can assist in assessing liver function.
 Explain that a blood sample is needed for the test.
 Potential Nursing Actions
 Measuring and trending abdominal girth can assist in monitoring the progression of ascites with
liver disease.
 Other options include enteral and parenteral nutrition as replacement strategies. Correlate
laboratory values with IV fluid infusion and collaborate with the health-care provider and
pharmacist to adjust to patient needs. Adequate pain and nausea control can improve caloric intake.
b.1. CREATININE KINASE -MB (CK-MB)
DEFINITION:
• Creatine kinase-MB (CK-MB) is a form of an enzyme found primarily in heart muscle cells. This
test measures CK-MB in the blood. CK-MB is one of three forms (isoenzymes) of the enzyme
creatine kinase (CK).
PURPOSE:
• To distinguish between skeletal muscle and heart muscle damage; sometimes to determine if you
have had a heart attack (if the troponin test is not available); sometimes to detect a second or
subsequent heart attack or to monitor for additional heart damage
INDICATIONS:
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
• Timing is important. If you have the test too soon after a heart attack, you may have a false-
negative result. Strenuous exercise and cocaine use can also affect your results.
PATIENT PREPARATION:
• You don't need to prepare for this test. Be sure your healthcare provider knows about all medicines,
herbs, vitamins, and supplements you are taking. This includes medicines that don't need a
prescription and any illicit drugs you may use.
NORMAL VALUES:
• Adult/elderly: (Values are higher after exercise):
• Male: 55-170 units/L
• Female: 30-135 units/L
• Newborn: 68-580 units/L
• CK-MM: 100%
• CK-MB: 0%
• CK-BB: 0%
PROCEDURE:
 Avoid IM injections in patients with cardiac disease. These injections may falsely elevate the total
CK level.
 Collect a venous blood sample. This is usually done initially and 12 hours later, followed by daily
testing for 3 days, and then at 1 week.
 Rotate the venipuncture sites.
 Avoid hemolysis.
 Record the date and time of any IM injection.
 Record the exact time and date of venipuncture on each laboratory slip. This aids in the
interpretation of the temporal pattern of enzyme elevations.
 Apply pressure or a pressure dressing to the venipuncture site and observe the site for bleeding.
IMPLICATIONS OF ABNORMAL RESULTS:
• Decreased clearance occurs in any condition that decreases renal blood flow and with impaired
kidney function, intrinsic renal disease, nephrotic syndromes, amyloidosis, shock, hemorrhage, and
congestive heart failure.
• Increased clearance occurs with high cardiac output, burns, and carbon monoxide poisoning.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Explain the procedure to the patient.
 Discuss with the patient the need and reason for frequent venipuncture in diagnosing MI.
 Tell the patient that no food or fluid restrictions are necessary.
b.2. LACTASE DEHYDROGENASE 1 & 2 (LD1, LD2)
DEFINITION:
• Different LDH isoenzymes are found in different body tissues. The areas of highest concentration
for each type of isoenzyme are: LDH-1: heart and red blood cells. LDH-2: heart and red blood cells.
LDH-3: lymph tissue, lungs, platelets, pancreas.
PURPOSE:
• Lactate dehydrogenase (LDH) is an enzyme required during the process of turning sugar into
energy for your cells. LDH is present in many kinds of organs and tissues throughout the body,
including the liver, heart, pancreas, kidneys, skeletal muscles, lymph tissue, and blood cells.
INDICATIONS:
• When illness or injury damages your cells, LDH may be released into the bloodstream, causing the
level of LDH in your blood to rise. High levels of LDH in the blood point to acute or chronic cell
damage, but additional tests are necessary to discover its cause. Abnormally low LDH levels only
rarely occur and usually aren’t considered harmful.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 The serum is preferred to plasma.
 The plasma may not be used due to the presence of platelets which have a high quantity of LDH.
 Separate the serum as soon as possible, immediately after the clot formation.
 Do not refrigerate or freeze and perform the test immediately.
 The hemolyzed serum has 150 times more LDH due to the RBCs, particularly LDH-1 and LDH-2
than the clear serum.
PATIENT PREPARATION:
• There are no food, fluid, activity, or medication restrictions unless by medical direction.
NORMAL VALUES:
AGE NORMAL LDH LEVEL
0 – 10 DAYS 290-2000 U/L
10 DAYS – 2 YEARS 180 – 430 U/L
2 – 12 YEARS 110 – 190 U/L
OLDER THAN 12 YEARS 100 – 190 U/L
PROCEDURE:
 You’ll have blood drawn through a needle inserted into a vein in your arm.
 For LDH tests of the cerebrospinal fluid, you’ll need a lumbar puncture (also called a spinal tap).
You’ll have a thin needle inserted into your lower back.
 Before either test, you should let your doctor know about all the medicines, supplements, herbs,
vitamins, and anything else you’re taking.
IMPLICATIONS OF ABNORMAL RESULTS:
• High levels of LDH indicate some form of tissue damage. High levels of more than one isoenzyme
may indicate more than one cause of tissue damage. For example, a patient with pneumonia could
also have a heart attack. Extremely high levels of LDH could indicate severe disease or multiple
organ failure.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 LDH isoenzyme levels should be interpreted in view of clinical findings
 Testing should be repeated in 3 consecutive days.
B. C-REACTIVE PROTEIN
DEFINITION:
• C-reactive protein (CRP) is a protein made by the liver. CRP levels in the blood increase when there is a
condition causing inflammation somewhere in the body. A CRP test measures the amount of CRP in the
blood to detect inflammation due to acute conditions or to monitor the severity of disease in chronic
conditions.
PURPOSE:
• To identify the presence of inflammation and to monitor response to treatment for an inflammatory
disorder
INDICATIONS:
• Monitor acute inflammation, bacterial infection, and acute tissue destruction.
• Evaluate progress of rheumatic fever under treatment and postoperative recovery.
• Predict cardiovascular disease risk.
• Monitor healing process in cases of burns and organ transplantation.
• Identify patients at higher risk of stenosis before percutaneous coronary intervention (PCI), such as
coronary stenting.
CONTRAINDICATIONS/PRECAUTIONS:
INTERFERRING FACTORS:
• Oral contraceptives and estrogens may affect CRP levels
• Smoking and exercise increase CRP levels
NORMAL VALUES:
• CRP is usually measured in milligrams of CRP per liter of blood (mg/L). Normal CRP levels are below 3.0
mg/L. Keep in mind the normal reference range often varies between labs. A high-sensitivity CRP test can
detect levels below 10.0 mg/L.
PROCEDURE:
• Bring all reagents and serum sample to Room Temperature and mix latex reagent gently prior to use. Do
not dilute the controls and serum.
• Place 1 drop of Serum, Positive control and Negative control on separate reaction circle on glass slide.
• Then add 1 drop of CRP latex reagent to each of the circles.
• Mix with separate mixing sticks and spread the fluid over the entire area of the cell.
• Tilt the slide back and forth slowly for 2 minutes observing preferably under artificial light.
• Observe for visible agglutination.
IMPLICATIONS OF ABNORMAL RESULTS:
• A high level of CRP in the blood is a marker of inflammation. It can be caused by a wide variety of
conditions, from infection to cancer. High CRP levels can also indicate that there’s inflammation in the
arteries of the heart, which can mean a higher risk of heart attack.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
• Managing Side Effects: Though you may experience some swelling, bruising, pain, or a hematoma
(pooling of blood in the skin) in the area in which your blood was drawn, these side effects should be
minor and usually go away within a few days. If they don't go away or they get worse, be sure to call your
doctor.

C. TROPONIN (TROPONIN 1, TROPONIN T)


DEFINITION:
• Troponin, or the troponin complex, is a complex of three regulatory proteins that is integral to muscle
contraction in skeletal muscle and cardiac muscle, but not smooth muscle. Blood troponin levels may be
used as a diagnostic marker for stroke, although the sensitivity of this measurement is low.
PURPOSE:
• To determine if you have had a heart attack or injury to heart muscle; to determine if your angina (chest
pain related to heart trouble) is worsening.
INDICATIONS:
• Troponin levels may also be elevated with other heart conditions such as myocarditis (heart inflammation),
weakening of the heart (cardiomyopathy), or congestive heart failure, and with conditions unrelated to the
heart, such as severe infections and kidney disease.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
• False-positive results: elevations in acute and chronic renal failure and chronic muscle disease.
PATIENT PREPARATION:
• None, but tell your healthcare practitioner or emergency department personnel about any over-the-counter
or prescription medications and/or supplements you take. There are no food, fluid, activity, or medication
restrictions unless by medical direction.
NORMAL VALUES:
• A negative test result refers to a normal test, where troponin is not detected in the blood. Results are given
in nanograms per milliliter (ng/mL). The normal range for troponin is between 0 and 0.4 ng/mL. Other
types of heart injury may cause a rise in troponin levels.
PROCEDURE:
• Troponin I test procedure is a quick, simple test using a few milliliters of blood from the patient’s vein.
The test timing must be minimum 6 to 12 hours after the start of cardiac symptoms. No prior test
preparation is required. The procedure takes around 10 minutes only using a rapid test kit. A blood sample
is drawn by a needle from a vein in your hand/finger.
IMPLICATIONS OF ABNORMAL RESULTS:
• Elevated troponin levels may result from sepsis, kidney failure, heart failure, or a traumatic injury to the
heart. Very high levels of troponin typically indicate that a person has had a heart attack, which can occur
if the blood supply to some of the heart muscle suddenly becomes blocked.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
• Apply pressure or a pressure dressing to the venipuncture site and monitor for bleeding or infection.
• Report all elevated enzyme levels to the physician immediately so that appropriate medical interventions
are not delayed.
• Evaluate outcomes and counsel the patient appropriately (eg, for newly diagnosed MI, consider the need
for lifestyle adjustment, rest, activity and diet changes, medications, work, and leisure activity).
• Further testing may be needed to monitor success of thrombolytic therapy for acute MIs.
D. BLOOD CHEMISTRY
LIPIDS
.1. TRIGLYCERIDE
DEFINITION:
• Triglycerides are a type of fat found in the blood. They are the most common type of fat in the
body. A triglyceride is an ester derived from glycerol and three fatty acids. Triglycerides are the
main constituents of body fat in humans and other vertebrates, as well as vegetable fat.
PURPOSE:
• Triglycerides and cholesterol are different types of lipids that circulate in your blood: Triglycerides
store unused calories and provide your body with energy. Cholesterol is used to build cells and
certain hormones.
INDICATIONS:
• High triglycerides are often a sign of other conditions that increase the risk of heart disease and
stroke, including obesity and metabolic syndrome — a cluster of conditions that includes too much
fat around the waist, high blood pressure, high triglycerides, high blood sugar and abnormal
cholesterol levels.
CONTRAINDICATIONS/PRECAUTIONS:
• High triglycerides may contribute to hardening of the arteries or thickening of the artery walls
(arteriosclerosis) — which increases the risk of stroke, heart attack and heart disease. Extremely
high triglycerides can also cause acute inflammation of the pancreas (pancreatitis).
INTERFERRING FACTORS:
 Failure to observe pretest restrictions
 Use of glycol-lubricated collection tube
 Failure to send the sample to the laboratory immediately.
 Antilipenics (decresed serum levels)
 Corticosteroids (long time use)
PATIENT PREPARATION:
• You should fast for 9 to 14 hours before the test and drink only water during that period. Your
doctor will specify how much time you should fast before the test. You should also avoid alcohol
for 24 hours before the test.
NORMAL VALUES:
 Normal — Less than 150 milligrams per deciliter (mg/dL), or less than 1.7 millimoles per liter
(mmol/L)
 Borderline high — 150 to 199 mg/dL (1.8 to 2.2 mmol/L)
 High — 200 to 499 mg/dL (2.3 to 5.6 mmol)
PROCEDURE:
• The test uses a blood sample that a laboratory will analyze. A healthcare provider will draw blood
from a vein in the front of your elbow or the back of your hand. They’ll follow these steps to get the
blood sample:
 They clean the site with an antiseptic and wrap an elastic band around your arm to allow blood
to fill the veins.
 They insert a needle into your vein and collect blood in a tube attached to the needle.
 Once the tube is full, they remove the elastic band and the needle. They then press against the
puncture site with a cotton ball or gauze to stop any bleeding
IMPLICATIONS OF ABNORMAL RESULTS:
• High levels of triglycerides (greater than 200 mg/dl) are associated with an increased risk of
atherosclerosis and therefore coronary artery disease and stroke. Extremely high triglyceride levels
(greater than 500mg/dl) may cause pancreatitis (inflammation of the pancreas).
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Apply direct pressure to the venipuncture site until bleeding stops.
 If a hematoma develops at the venipuncture site, continue direct pressure.
 Tell that patient that he may resume his usual diet and medication that was discontinued before the
test, as ordered.
.2. TOTAL CHOLESTROL
DEFINITION:
• Total cholesterol is the total amount of cholesterol in your blood. Your total cholesterol includes
low-density lipoprotein (LDL, or “bad”) cholesterol and high-density lipoprotein (HDL, or“good”)
cholesterol. Cholesterol is a waxy, fat-like substance found in every cell in your body.
PURPOSE:
• Keeping total cholesterol levels within a healthy range is important for people of all ages, whether
they have heart disease or not. If like many people, you have high blood cholesterol and don’t know
it, the only way you can find out is by having your blood tested.
INDICATIONS:
• Your doctor may order a cholesterol test as part of a routine exam, or if you have a family history of
heart disease or one or more of the following risk factors:
 High blood pressure.
 Type 2 diabetes.
 Smoking.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
• Drugs such as birth control pills, hormone replacement therapy, steroids, and blood pressure
medication such as beta-blockers and diuretics can raise cholesterol levels and affect cholesterol
test results. Precaution, if you're having a complete lipid profile done, you should avoid eating or
drinking anything other than water for nine to 12 hours before your test.
PATIENT PREPARATION:
• You may need to fast--no food or drink--for 9 to 12 hours before your blood is drawn. Your health
care provider will let you know if you need to fast and if there are any special instructions to
follow.
NORMAL VALUES:
• Desirable level: Less than 200 mg/dL
• Borderline high level: 200-239 mg/dL
• High level: 240 mg/dL and above
PROCEDURE:
 During the procedure
 A cholesterol test is a blood test, usually done in the morning since you'll need to fast for the
most accurate results. Blood is drawn from a vein, usually from your arm.
 Before the needle is inserted, the puncture site is cleaned with antiseptic and an elastic band is
wrapped around your upper arm. This causes the veins in your arm to fill with blood.
 After the needle is inserted, a small amount of blood is collected into a vial or syringe. The
band is then removed to restore circulation, and blood continues to flow into the vial. Once
enough blood is collected, the needle is removed and the puncture site is covered with a
bandage.
 The procedure will likely take a couple of minutes. It's relatively painless.
IMPLICATIONS OF ABNORMAL RESULTS:
• High cholesterol can cause a dangerous accumulation of cholesterol and other deposits on the walls
of your arteries (atherosclerosis). These deposits (plaques) can reduce blood flow through your
arteries, which can cause complications
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
• There are no precautions you need to take after your cholesterol test. You should be able to drive
yourself home and do all your normal activities. You might want to bring a snack to eat after your
cholesterol test is done, if you've been fasting.
.3. PHOSPHOLIPIDS
DEFINITION:
• A phospholipid is a type of lipid molecule that is the main component of the cell membrane. Lipids
are molecules that include fats, waxes, and some vitamins, among others. Each phospholipid is
made up of two fatty acids, a phosphate group, and a glycerol molecule. When many phospholipids
line up, they form a double layer that is characteristic of all cell membranes
PURPOSE:
• Phospholipids provide barriers in cellular membranes to protect the cell, and they make barriers for
the organelles within those cells. Phospholipids work to provide pathways for various substances
across membranes.
INDICATIONS:
• In addition to assembling the membrane, phospholipids are also used to assemble the circulating
lipoproteins, the main task of which is to transport lipophilic triglycerides and cholesterols through
the hydrophilic blood. The human body uses phospholipids as emulsifiers.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
• Both aPL immunoassays and coagulation assays are prone to interferences, and clinicians need to
be aware of the limitations of these assays. Interference is a clinically significant bias in the
measured analyte concentration due to the effect of another component or property of the sample.
EQUIPMENTS:
 Red-top tube or gel-barrier tube
 Patient should fast for 12 to 14 hours.
NORMAL VALUES:
• Adults: 1.61 – 3.55 mmol/L 125 – 275 mg/dL
• Newborns: 0.90 – 2.19 mmol/L 70 – 170 mg/dL
• Infants: 1.29 – 3.55 mmol/L 100 – 275 mg/dL
• Children: 2.32 – 3.81 mmol/L 180 – 295 mg/dL
PROCEDURE:
IMPLICATIONS OF ABNORMAL RESULTS:
•Abnormal phospholipid levels have been associated with obstructive jaundice, abeta- or
hypobetalipoproteinemia, Tangier disease, and LCAT deficiency.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
• Evaluate outcomes and counsel the patient appropriately (eg, for high cholesterol levels instruct on
the importance of decreased animal fat, replacement of saturated fats with polyunsaturated fats, a
consistent exercise program, maintenance of an appropriate body weight, and stress reduction).
• Monitor the venipuncture site for bleeding or infection and allow the patient to resume the pretest
diet and medications.
LIPOPROTEINS
d.4. LIPOPROTEIN-CHOLESTROL FRACTIONATION
DEFINITION:
• Ion mobility lipoprotein fractionation is a technology that uses gas-phase (laminar flow)
electrophoresis to separate unmodified lipoproteins on the basis of size. ... Ionized lipoprotein
particles are electrophoretically separated in a gas phase, and lipoprotein particles are distinguished
on the basis of size.
PURPOSE:
• These tests are performed to evaluate the risk for myocardial or coronary artery occlusion and
coronary heart disease and to determine total cholesterol, the “bad” cholesterol (LDL-C), and the
“good” cholesterol (HDL-C), and triglyceride levels.
INDICATIONS:
• Cholesterol screens for coronary heart disease risk factors, part of a lipid profile.
• Assess other diseases, such as liver, biliary, thyroid, and renal diseases, and diabetes mellitus.
• Monitor the effectiveness of diet, medication, lifestyle changes (eg, exercise), and stress
management on test outcomes and lowered risk.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
• Cholesterol normally has slight seasonal variations: Levels are higher in the fall and winter and
lower in the spring and summer; pregnancy increases levels; positional variations.
• Drugs that cause decreased levels include thyroxine, estrogens, androgens, aspirin, antibiotics
(tetracycline and neomycin), nicotinic acid, heparin, colchicine, MAO inhibitors, allopurinol, and
bile salts.
• Drugs that may cause increased levels include oral contraceptives, epinephrine, phenothiazines,
vitamins A and D, phenytoin, ACTH, anabolic steroids, beta-adrenergic blocking agents,
sulfonamide, and thiazide diuretics.
NORMAL VALUES:
• Normal values vary with age, diet, and geographic location. The desirable values are given in the
following ranges
 Adults:
Desirable level: 140–199 mg/dL or 3.63–5.15 mmol/L
Borderline high: 200–239 mg/dL or 5.18–6.19 mmol/L
High: 240 mg/dL or 6.20 mmol/L
 Children and adolescents (12–18 years):
Desirable level: 170 mg/dL or 4.39 mmol/L
Borderline high: 170–199 mg/dL or 4.40–5.16 mmol/L
High: 200 mg/dL or 5.18 mmol/L
PROCEDURE:
• Blood (5–10 mL) is obtained by venipuncture, using a red-top Vacutainer tube.
• A foam pad with a liquid enzyme (Prevu Skin Sterol Test) is placed on the palm. A change in
liquid color is compared against a color chart that correlates with the amount of cholesterol.
IMPLICATIONS OF ABNORMAL RESULTS:
• Elevated cholesterol levels (hypercholesteremia) occur in cardiovascular disease and
atherosclerosis, type II familial hypercholes- terolemia, hyperlipoproteinemia, hepatocellular
disease, biliary cirrhosis, hypothyroidism, von Gierke’s disease, pancreatic and prostate
neoplasms, Werner’s syndrome, poorly controlled diabetes mellitus, chronic nephritis,
glomerulosclerosis, obesity, and dietary “affluence.”
• Decreased cholesterol levels (hypocholesteremia) occur in malab- sorption, starvation, severe liver
disease, hyperthyroidism, chronic obstructive lung disease, mesoblastic, sideroblastic, chronic
anemias, Tangier disease, severe burns, acute illness, chronic obstructive lung disease, and mental
retardation.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
• Monitor the venipuncture site for bleeding or infection and allow the patient to resume the pretest
diet and medications.
Evaluate outcomes and counsel the patient appropriately (e.g., for high cholesterol levels instruct

on the importance of decreased animal fat, replacement of saturated fats with polyunsaturated fats,
a consistent exercise program, maintenance of an appropriate body weight, and stress reduction).
.5. LIPOPROTEIN PHENOTYPING
DEFINITION:
• Atherogenic lipoprotein phenotype. A proposed genetic marker for coronary heart disease risk.
Austin MA(1), King MC, Vranizan KM, Krauss RM. ... Phenotype A was characterized by
predominance of large, buoyant LDL particles, and phenotype B consisted of a major peak of
small, dense LDL particles.
PURPOSE:
• A Lipoprotein Phenotyping Profile Blood Test is used to evaluate hyperlipidemia (high
Cholesterol) to determine abnormal lipoprotein distribution and concentration in the serum.
INDICATIONS:
 Evaluate known or suspected disorders associated with altered lipoprotein levels
 Evaluate patients with serum cholesterol levels greater than 250 mg/dL, which indicate a high risk
for CAD
 Evaluate the response to treatment for high cholesterol and determine the need for drug therapy
CONTRAINDICATIONS/PRECAUTIONS:
INTERFERRING FACTORS:
 Failure to follow usual diet for 2 wk before the test can yield results that do not accurately reflect
the patient’s cholesterol values.
 Ingestion of alcohol 24 hr before the test, ingestion of food 12 hr before the test, and excessive
exercise 12 hr before the test can alter results.
 Numerous drugs can alter results (see monographs titled “Cholesterol, Total” and “Triglycerides”).
 Failure to follow dietary restrictions before the procedure may cause the procedure to be canceled
or repeated.
PATIENT PREPARATION:
• Patient should be on stable diet ideally for two to three weeks prior to collection of blood, and
should fast for 12 to 14 hours before collection of the specimen.
NORMAL VALUES:
• Optimal: 100 mg/dL or 2.85 mmol/L
• Near optimal: 130 mg/dL or3.37 mmol/L
• Borderline high: 130–159 mg/dL or 3.37–4.12 mmol/L
• High: 160–189 mg/dL or 4.14–4.90 mmol/L
• Very high: 190 mg/dL or 4.92 mmol/L
PROCEDURE:
• Blood (5–10 mL) is obtained by venipuncture, using a red-top Vacutainer tube.
• A foam pad with a liquid enzyme (Prevu Skin Sterol Test) is placed on the palm. A change in
liquid color is compared against a color chart that correlates with the amount of cholesterol.
IMPLICATIONS OF ABNORMAL RESULTS:
• In this condition, there is a high concentration of β-lipoprotein with normal pre−β-lipoprotein. The
α-lipoprotein is normal or sometimes slightly decreased. The calculated LDL-cholesterol value
should be >160 mg/dL. This is a relatively common disorder.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Inform the patient that a report of the results will be made available to the requesting health-care
provider (HCP), who will discuss the results with the patient.
 Instruct the patient to resume usual diet, fluids, and activity, as directed by the HCP.
 Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral
to another HCP. Answer any questions or address any concerns voiced by the patient or family.
 Depending on the results of this procedure, additional testing may be performed to evaluate or
monitor progression of the disease process and determine the need for a change in therapy.
Evaluate test results in relation to the patient’s symptoms and other tests performed.
E. HEMATOLOGY
e.1. RED BLOOD CELL COUNT
DEFINITION:
 Is a blood test used to find out how many red blood cells you have
 Also known as an erythrocyte count
PURPOSE:
 To evaluate the number of red blood cells
 To screen for, help diagnose, or monitor conditions affecting red blood cells
INDICATIONS:
 Identify:
 Anemia
 Blood loss
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Many physiologic variants affect outcomes: posture, exercise, age, altitude, pregnancy, and many
drugs.
 Excessive exercise, anxiety, pain, and dehydration may lead to false elevations.
 Hemodilution in the presence of a normal number of RBCs may lead to false decreases (e.g.,
excessive administration of intravenous fluids, normal pregnancy).
 Many drugs may cause a decrease in circulating RBCs.
 Drugs such as methyldopa and gentamicin may cause an elevated RBC count.
EQUIPMENTS:
 Hemocytometer or improved Neubauer’s chamber
 RBC pipette
NORMAL VALUES:
 NEWBORN: 4.8–7.1 million/mm3; 4.8–7.1 x 10^12/L (SI units)
 1 Mo: 4.1–6.4 million/mm3
 6 Mo: 3.8–5.5 million/mm3
 1-10 Yr: 4.5–4.8 million/mm3
 MALE: 4.6–6.2 million/mm3
 FEMALE: 4.2–5.4 million/mm3
PROCEDURE:
 Your doctor will draw blood from your vein, usually on the side of your elbow.
 The healthcare provider will clean the puncture site with an antiseptic.
 They will wrap an elastic band around your upper arm to make your vein swell with blood.
 They will gently insert a needle into your vein and collect blood in an attached vial or tube.
 They will then remove the needle and elastic band from your arm.
 The healthcare provider will send your blood sample to a laboratory for analysis.
IMPLICATIONS OF ABNORMAL RESULTS:
 Increased levels:
 Dehydration
 Polycythemia vera
 COPD
 High altitude
 Congenital heart disease
 Pulmonary fibrosis
 CorPulmonae
 Thalassemia trait
 Decreased levels:
 Chemotherapy
 Anemia
 Hemorrhage
 Bone marrow failure
 Erythropoetin deficiency
 Hemolysis
 Leukemia
 Multiple myeloma
 Malnutrition
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Care and assessment after the procedure are the same as for any study involving the collection of a
peripheral blood sample.
 Anemia: Note and report signs and symptoms of anemia associated with decreased counts in
combination with Hgb and HCT decreases. Prepare to administer ordered oral or parenteral iron
preparation or a transfusion of whole blood or packed RBCs. Prepare for phlebotomy if levels are
increased in polycythemia vera or secondary polycythemia.
 Monitor the puncture site for oozing or hematoma formation.
 Instruct to resume normal activities and diet.
.2. HEMATOCRIT
DEFINITION:
 Also known as packed-cell volume (PCV) test, is a simple blood test
PURPOSE:
 To measure the ratio of red blood cells in your blood
 Measuring the proportion of red blood cells in your blood can help your doctor make a diagnosis or
monitor your response to a treatment
INDICATIONS:
 Routine screening as part of a CBC
 Along with an Hgb (i.e., an “H and H”), to monitor blood loss and response to blood replacement
 Along with an Hgb, to evaluate known or suspected anemia and related treatment
 Along with an Hgb, to monitor hematologic status during pregnancy
 Monitoring responses to fluid imbalances or to therapy for fluid imbalances:
 A decreased Hct may indicate hemodilution.
 An increased Hct may indicate dehydration.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Physiologic variants affect Hct outcomes: age, sex, and physiologic hydremia of pregnancy.
 Abnormalities in RBC size and extremely elevated WBC counts may alter Hct values.
 Elevated blood glucose and sodium may produce elevated Hct values because of swelling of the
erythrocyte.
 Factors that alter the RBC count such as hemodilution and dehydration also influence the Hct.
EQUIPMENTS:
PATIENT PREPARATION:
 Before getting the test, let your doctor know if you’ve recently had a blood transfusion or are
pregnant. Pregnancy can decrease your blood urea nitrogen (BUN) levels due to increased fluid in
your body. A recent blood transfusion can also affect your results. If you live at a high altitude,
your hematocrit levels tend to be higher due to reduced amounts of oxygen in the air.
 If your health care provider has ordered more tests on your blood sample, you may need to fast (not
eat or drink) for several hours before the test. Your health care provider will let you know if there
are any special instructions to follow.
NORMAL VALUES:
 MEN: 42%–52% or 0.42–0.52
 WOMEN: 36%–48% or 0.36–0.48
PROCEDURE:
 A healthcare professional will take a blood sample from a vein in your arm using a small needle.
 After the needle is inserted, a small amount of blood will be collected into a test tube or vial. You
may feel a little sting when the needle goes in or out. This usually takes less than 5 minutes.
IMPLICATIONS OF ABNORMAL RESULTS:
 Hct or packed cell volume (PCV) decreases are an indication of anemia. An Hct of 30% or less
means that the patient is moderately to severely anemic.
 Hct is decreased in leukemia, lymphomas, Hodgkin’s disease, adrenal insufficiency, hemolytic
reaction, and chronic disease.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Care and assessment after the procedure are the same as for any study involving the collection of a
peripheral blood sample.
 Critical values:
 Notify the physician at onces if the Hct is greater than 60 percent or less than 14 percent.
 Prepare the client for possible transfusion of blood products or infusion of intravenous fluids
and for further procedures to evaluate the cause or source of the blood loss or
hemoconcentration.
 Monitor the puncture site for oozing or hematoma formation.
 Instruct to resume normal activities and diet.
.3. RED CELL INDICES
DEFINITION:
 Are part of the complete blood count
 Are used to help diagnose the cause of anemia
PURPOSE:
 Measures how well the RBCs carry hemoglobin and oxygen to our body’s cells
INDICATIONS:
 Average red blood cell size (MCV)
 Hemoglobin amount per red blood cell (MCH)
 The amount of hemoglobin relative to the size of the cell (hemoglobin concentration) per red blood
cell (MCHC)
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Because RBC indices are calculated from the results of the RBC count, Hgb, and Hct, factors that
influence the latter three tests (e.g., abnormalities of RBC size, extremely elevated WBC counts)
also influence RBC indices.
EQUIPMENTS:
NORMAL VALUES:
 MCV: 80-100 femtoliter
 MCH: 27-31 picograms/cell
 MCHC: 32-36 (g/dL) or 320-360 (g/L)
PROCEDURE:
 The test for RBC indices involves taking a small sample of blood. You don’t need to prepare for the
test. The following steps describe what happens:
 If the blood is taken from a vein inside your elbow, a healthcare provider will first clean the test
area with an antiseptic and wrap an elastic band around your upper arm to make the vein swell.
 A needle is gently inserted, and blood flows into a tube.
 When the tube is filled, the healthcare provider removes the elastic band and then removes the
needle.
 A bandage may be placed over the area where the needle was inserted.
 The sample is then sent to a laboratory for analysis.
IMPLICATIONS OF ABNORMAL RESULTS:
 MCV below normal. Microcytic anemia ( may be due to low iron levels, lead poisoning, or
thalassemia)
 MCV above normal. Macrocytic anemia (may be due to low folate or B12 levels, or chemotherapy)
 MCH below normal. Hypochromic anemia (often due to low iron levels)
 MCH above normal. Hyperchromic anemia (may be due to low folate or B12 levels, or
chemotherapy)
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Your doctor may also perform other tests to make a diagnosis. Treatment for any anemia depends
on the underlying cause. For example, if your anemia is caused by iron deficiency, your doctor may
advise you to take iron supplements or change your diet to include more foods that are rich in iron.
If you have an underlying disease that’s causing anemia, treatment for that disease can often also
improve the anemia.
e.4. ERYTHROCYTE SEDIMENTATION RATE
DEFINITION:
 This test measures the sedimentation rate or settling of RBCs and is used as a nonspecific measure
of many diseases, especially inflammatory conditions.
PURPOSE:
 When you’re experiencing inflammation, your red blood cells (RBCs) cling together, forming
clumps. This clumping affects the rate at which RBCs sink inside a tube where a blood sample is
placed. The test lets your doctor see how much clumping is occurring.
 The test can identify and measure inflammation, in general, in your body. However, it doesn’t help
pinpoint the cause of inflammation. That’s why the ESR test is rarely performed alone.
 The ESR test can be used to help your healthcare provider diagnose conditions that cause
inflammation.
 The ESR test can help your healthcare provider monitor autoimmune inflammatory conditions, such
as: rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE).
INDICATIONS:
 Diagnose inflammatory disease, rheumatic fever, rheumatoid arthritis, respiratory infections, and
temporal arthritis.
 Monitor steroid treatment of inflammatory disease.
 Suspected organic disease when symptoms are vague and clinical findings uncertain
 Identification of the presence of an inflammatory or necrotic process
 Monitoring response to treatment for various inflammatory disorders (e.g., rheumatoid arthritis,
systemic lupus erythematosus)
 Support for diagnosing disorders associated with altered ESRs
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Increased in pregnancy (after 12 weeks), postpartum, menstruation, drugs (heparin and oral
contraceptives), presence of cholesterol, globulins, fibrinogen, C-reactive protein, and anemia.
 Decreased with certain drugs (steroids, aspirin) and decreased fibrinogen level in newborns, and
blood specimens allowed to stand before testing (24 hours), high glucose, high albumin, high
phospholipids, and high RBC and WBC counts.
EQUIPMENTS:
PATIENT PREPARATION:
 Explain purpose and procedure.
 Obtain appropriate medication history.
 Fasting is not necessary, but a fatty meal may cause plasma alterations
NORMAL VALUES:
 Same for standard and SI units.
 Men: Aged <50: 0–14 mm/hour; 50–85 years: 0–19 mm/hour; >85 years: 0–29 mm/hour
 Women: Aged <50: 0–19 mm/hour; 50–85 years: 0–29 mm/hour; >85 years: 0–41 mm/hour
 Children: 0–10 mm/hour
PROCEDURE:
 A 4.0 mL of whole-blood specimen is obtained by venipuncture in a lavender-top tube.
 Do not allow blood sample to stand more than 24 hours, as rate can be falsely decreased.
IMPLICATIONS OF ABNORMAL RESULTS:
 Increased rate is seen in inflammation, collagen and autoimmune disorders, infections, subacute
bacterial endocarditis, cancers, toxemia, heavy metal poisoning, nephritis, anemia, gout, myocardial
infarct, malignancy, and multiple myeloma.
 Normal or no increase is seen in polycythemias, sickle cell anemia, spherocytosis, congestive heart
failure, hypofibrinogenemia, and pyruvate kinase deficiency.
 Variable deviations can be seen in acute disease, convalescence, unruptured acute appendicitis,
angina pectoris, viral diseases and infectious mononucleosis, renal failure, allergy, and peptic ulcer.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Evaluate patient outcomes and counsel appropriately about inflammation, anemia, or collagen and
autoimmune disorders, among others.
 Explain need for repeat testing to monitor progress and evaluate prescribed therapy.
.5. RETICULOCYTE COUNT
DEFINITION:
 This test measures immature nonnucleated red blood cells and is done in the differential diagnosis
of anemia. Reticulum is present in newly released blood cells for 1–2 days before the cell reaches
its full mature state.
PURPOSE:
 To help your doctor learn if your bone marrow is producing enough red blood cells.
 To help your doctor make a diagnosis of a variety of conditions, such as anemia or bone marrow
failure.
 To help monitor your progress and health after you undergo chemotherapy, radiation therapy, a
bone marrow transplant, or treatment on iron deficiency anemia
INDICATIONS:
 Differentiate anemias due to bone marrow failure in aplastic anemia from those due to hemorrhage
or red blood cell destruction.
 Monitor effectiveness of treatment in pernicious anemia (treatment with vitamin B12 or
transfusion) and recovery of bone marrow function.
 Determine radiation effects on patients and exposed workers
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Specimen older than 24 hours affects outcome.
 Recent transfusion decreases values.
 Hemophilia
 History of fainting
EQUIPMENTS:
PATIENT PREPARATION:
 Your doctor may ask you to avoid eating anything, drinking anything, or both.
 Your doctor may also ask you to avoid taking certain medications beforehand, such as blood
thinners.
 Explain purpose and procedure of testing.
 You should also tell your doctor about any medications you are taking, including prescription and
OTC drugs.
NORMAL VALUES:
 Men: 0.5%–1.5% (expressed as % of total erythrocytes) or 0.005–0.015
 Women: 0.5%–2.5% or 0.005–0.025
 Infants: 2%–5% or 0.02–0.05 Children: 0.5%–4% or 0.005–0.04
 Reticulocyte index (RI) = 1.0 or 1% increase in RBC production above normal or corrected
reticulocyte count (CRC)
PROCEDURE:
 A 5-mL blood sample is obtained by venipuncture in a lavendertop tube. Place the specimen in a
biohazard bag.
 A blood smear is prepared after mixing blood with a supravital stain and examined microscopically.
IMPLICATIONS OF ABNORMAL RESULTS:
 Reticulocytes increase (reticulocytosis) in hemolytic anemias, hemoglobinopathies, sickle cell
anemias, 3–4 days after hemorrhage, increased RBC destruction, and treatment of anemias and
malaria.
 Reticulocytes decrease in iron deficiency and aplastic anemia, untreated pernicious anemia, chronic
infection, radiation therapy and exposure, marrow tumors, endocrine disorders, myelodysplastic
syndromes, and alcoholism.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Evaluate patient outcome and counsel regarding possible repeat testing.
 Recently approved treatment for myelodysplastic syndromes include demethylating agents, e.g.,
azacitidine and decitabine
.6. OSMOTIC FRAGILITY
DEFINITION:
 Determines the ability of the RCB membrane to resist rupturing in a hypotonic saline solution.
Normal disk-shaped cells can imbibe water and swell significantly before membrane capacity is
exceeded, but spherocytes (RBCs that lack the normal biconcave shape) and cells with damaged
membranes burst in saline solutions only slightly less concentrated than normal saline.
PURPOSE:
 The test may also be used to help confirm if thalassemia or spherocytosis is the cause of anemia
INDICATIONS:
 Confirmation of disorders that alter RBC fragility, including hereditary anemias
 Evaluation of the extent of extrinsic damage to RBCs from burns, inadvertent instillation of
hypotonic intravenous fluids, microorganisms, and excessive exercise
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Membrane composition, ion transports, aquaporin action, lipid peroxidation, and eryptosis of
erythrocytes are involved in the variability of osmotic fragility
EQUIPMENTS:
NORMAL VALUES:
 A normal result is called a negative result.
PROCEDURE:
 If you’re wearing a long sleeved shirt, the technician will ask you to roll up one of your sleeves or
to remove your arm from the sleeve.
 The technician will tie an elastic strip tightly around your upper arm to help blood pool in the veins.
 The technician will find a vein and clean the area with an antiseptic. They’ll insert a hollow needle
into the vein.
 After collecting enough blood, the technician will remove the needle. You’ll need to keep pressure
on the puncture for a few seconds.
 Then, the technician will cover the spot with a bandage
IMPLICATIONS OF ABNORMAL RESULTS:
 If your red blood cells are more fragile than normal, the test is considered positive.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 If your osmotic fragility test is positive, the next step is to confirm the results and test whether you
are actively anemic.
.7. TOTAL HEMOGLOBIN
DEFINITION:
• A test used to determine the amount of hemoglobin in the blood. Hgb is the pigment part of the
erythrocyte, and the oxygen-carrying part of the blood.
PURPOSE:
• To check your overall health.
• To diagnose a medical condition.
• To monitor a medical condition.
INDICATIONS:
• Routine screening as part of a CBC
• Along with an Hct (i.e., an “H and H”), to evaluqte known or suspected anemia and related
treatment
• Along with an Hct, to monitor blood loss and response to blood replacement
• Along with an Hct,to monitor hematologic status during pregnancy
• If you have:
 Symptoms of anemia, which include weakness, dizziness, pale skin, and cold hands and feet
 A family history of thalassemia, sickle cell anemia, or other inherited blood disorder
 A diet low in iron and minerals
 A long-term infection
 Excessive blood loss from an injury or surgical procedure.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
• If you've had a reaction when having a blood test before, you can expect the same with this test
(e.g., puncture site soreness). If you tend to get squeamish around blood or needles, you may feel
dizzy or lightheaded.
• While it's rare, there is a slight risk of infection, especially if the area of needle insertion becomes
exposed or gets dirty before the skin heals.
EQUIPMENTS:
• If your blood sample is being tested only for hemoglobin, you can eat and drink normally before the
test. If your blood sample will be used for other tests, you may need to fast for a certain amount of
time before the sample is taken. Your doctor will give you specific instructions
NORMAL VALUES:
• MALES: 12-17 grams/100ml
• FEMALES: 11-15 grams/100ml
PROCEDURE:
• A member of your health care team takes a sample of blood by pricking your fingertip or inserting a
needle into a vein in your arm. For infants, the sample may be obtained by pricking the heel.
• The blood sample is sent to a lab for analysis. You can return to your usual activities immediately
after the sample is taken.
IMPLICATIONS OF ABNORMAL RESULTS:
• A Low hemoglobin level indicates anemia. Estimates of Hgb in each RBC are moderately
important when determining the total blood Hgb. However, hemoglobin findings are even more
dependent upon the total number of RBC's. In other words, for the diagnosis of anemia, the number
of RBC's is as important as the hemoglobin level.
• If a hemoglobin test shows a higher than normal level, there are several potential causes — the
blood disorder polycythemia vera, living at a high altitude, smoking and dehydration.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
• Care and assessment after the procedure are the same as for any study involving the collection of a
peripheral blood sample.
• Critical values: Notify the physician at once if the Hgb is less than 6.0 g/dL. Prepare the client for
possible transfusion of blood products and for further procedures to evaluate cause or source of
blood loss.
.8. HEMOGLOBIN ELECTROPHORESIS
DEFINITION:
• Is used as a screening test to identify normal and abnormal hemoglobins and assess their quantity
• Also called “hemoglobin evaluation” or “sickle cell screen”
PURPOSE:
• Helps your doctor figure out if you have a blood disorder and what type of blood disorder it is
• As part of a routine check-up.
• To diagnose blood disorders
• To monitor treatment
• To screen for genetic conditions
INDICATIONS:
• Suspected thalassemia, especially in individuals with positive family history for the disorder
• Differentiation among the types of thalassemias
• Evaluation of a positive Sickledex test to differentiate sickle cell trait (20 to 40 percent Hgb S) from
sickle cell disease (70 percent Hgb S)
• Evaluation of hemolytic anemia of unknown etiology
• Diagnosis of Hgb C anemia
• Identification of the numerous types of abnormal Hgb, most of which do not produce clinical
disease
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
• Rough handling will interfere with the results.
EQUIPMENTS:
PATIENT PREPARATION:
• You don’t need to do anything special to get ready for this test. But you should tell your doctor if
you had a blood transfusion in the past 12 weeks. If so, the test could produce a false result.
NORMAL VALUES:
CONVENTIONAL UNITS SI UNITS
Hgb A 95–97% >0.95
Hgb A2 2-3% 0.02-0.03
Hgb F >1% >0.01
Methemoglobin (Hgb M) 2% or 0.06-0.24 g/dL
Sulfhemoglobin Minute amounts
Carboxyhemoglobin 0-2.3%
4-5% in smokers
PROCEDURE:
• The test involves taking blood with a needle.
• At the lab, a technician will put the blood on special paper and zap it with electricity. The
hemoglobins move around and form lines on the paper that show how much each type you have.
IMPLICATIONS OF ABNORMAL RESULTS:
• If your results show abnormal hemoglobin levels, they may be caused by:
 Hemoglobin C disease, a genetic disorder that leads to severe anemia
 Rare hemoglobinopathy, a group of genetic disorders causing the abnormal production or
structure of red blood cells
 Sickle cell anemia
 Thalassemia
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
• Care and assessment after the procedure are the same as for any study involving the collection of
a peripheral blood sample.
• Complications and precautions: Note and report signs and symptoms associated with the
specific type of anemia identified by electrophoresis. Prepare to instruct in therapy and
prevention of complications. Offer information about genetic factors and counseling or both, if
appropriate.
.9. HEMOGLOBIN S TEST
DEFINITION:
• This test looks for an abnormal type of hemoglobin called hemoglobin S in our blood
• This test is routinely done as a screening for sickle cell anemia or trait and to confirm these
disorders
PURPOSE:
• To test if you have symptoms of sickle cell disease or if you are being screened to see if you carry
the Hgb S gene
INDICATIONS:
• Screen for sickle cell disease or trait.
• Include as part of workup following the detection of sickle-shaped cells on peripheral blood
smear.
• Confirm sickle cell trait and diagnose sickle cell anemia.
• Evaluate hemolytic anemias.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
• False-positive results are due to other abnormal hemoglobins (D and G).
• False-negative results in patients with pernicious anemia and polycythemia.
• Infants younger than 3 months have false-negative results owing to a high amount of Hb F.
EQUIPMENTS:
PATIENT PREPARATION:
• You don’t have to prepare for this test.
• Make sure to tell your healthcare provider about any health conditions you have and blood
transfusions you may have had in the past.
• Be sure your healthcare provider knows about all medicines, herbs, vitamins, and supplements
you are taking. This includes medicines that do not need a prescription and any illicit drugs you
may use.
NORMAL VALUES:
• Normal results are negative, meaning no sickle cells were seen.
PROCEDURE:
• The test is done with a blood sample. A needle is used to draw blood from a vein in your arm or
hand.
• In small children or infants, blood can be taken by a skin prick from the heel of the foot.
IMPLICATIONS OF ABNORMAL RESULTS:
• Positive results mean sickle cells were seen. This may also mean that you have another blood
disease and may need more tests.
• Sickle cell trait: Definite confirmation of sickle cell trait by hemoglobin electrophoresis reveals
the following heterozygous (A/S) pattern: Hb S, 20%–40%; HbA1, 60%–80%; Hb F, small
amount. This means that the patient has inherited a normal Hb gene from one parent and an Hb S
gene from the other (heterozygous pattern). This patient does not have any clinical manifestations
of the disease, but some of the children of this patient may inherit the disease if the patient’s mate
also has the recessive gene pattern.
• Sickle cell anemia: Definite confirmation of sickle cell anemia by hemoglobin electrophoresis
reveals the following homozygous (S/S) pattern: Hb S, 80%–100%; Hb F, most of the rest;
HbA1, 0% or small amount. This means that an abnormal Hb S gene has been inherited from both
parents (homozygous pattern). Such a pattern has all the clinical manifestations of the disease.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
• Evaluate patient outcome and counsel and monitor appropriately.
• Advise genetic counseling if outcomes reveal sickle cell trait or anemia.
• Prenatal testing can be performed to determine whether the fetus will have sickle cell disease,
carry the trait, or be unaffected. In three of four cases, if both parents carry the gene, the prenatal
test will reveal that the fetus will not have sickle cell disease.
.10. UNSTABLE HEMOGLOBIN
DEFINITION:
• The unstable hemoglobin result from the presence of a structurally abnormal hemoglobin variant
with the substitution or deletion of amino acid in the red cell
PURPOSE:
• Testing for hemoglobinpathies is useful in cases of unexplained hemolytic anemia or when there is
a known familial pathogenic hemoglobin variant
INDICATIONS:
• Testing for hemoglobinpathies is useful in cases of unexplained hemolytic anemia or when there is
a known familial pathogenic hemoglobin variant
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
• Completely fill the collection tube, and invert it gently several times to mix the sample and the
anticoagulant thoroughly.
• To avoid hemolysis, do not shake the tube vigorously.
EQUIPMENTS:
• Explain to the patient that this test is used to detect abnormal hemoglobin in the blood.
• Tell him that a blood sample will be taken. Explain who will perform the venipuncture and when.
• Reassure him that drawing a blood sample will take less than 3 minutes.
• Explain that he may feel slight discomfort from the tourniquet pressure and the needle puncture.
• As necessary, withhold antimalarials, furazolidone (from infants), nitrofurantoin, phenacetin,
procarbazine, sulfonamides before the text because these drugs may induce hemolysis. If these
medications must be continued, note this on the laboratory slip.
Inform the patient that food or fluids need not be restricted before the test
NORMAL VALUES:
• When no unstable Hb appears in the sample, the heat stability test result is negative; the isopropanol
solubility test result is reported as stable.
PROCEDURE:
• Perform a venipuncture, and collect the sample in a 7-mllavender-top tube.
• Resume administration of medications withheld before the test.
IMPLICATIONS OF ABNORMAL RESULTS:
• A positive heat stability test result or unstable solubility test result, especially with hemolysis,
strongly suggests the presence of unstable Hb.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
• If a hematoma develops at the venipuncture site, apply warm soaks.
.11. HEINZ BODIES
DEFINITION:
• Are clumps of damaged hemoglobin located on red blood cells
• Are associated with both genetic and environmental factors and are linked to certain blood
conditions, like hemolytic anemia
PURPOSE:
• To help detect causes of hemolytic anemia
INDICATIONS:
• Following up to results of a low red blood cell count and elevated bilirubin
• Investigating hemolytic anemia after a splenectomy-
• Yellowing of the whites of the eyes (jaundice)
• Fatigue
• Pale appearance
• Shortness of breath
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
• Completely fill the sample collection tube and invert it gently several times to mix the sample and
the anticoagulant; do not shake the tube vigorously.
• Failure to fill the collection tube completely, to use the appropriate anticoagulant, to adequately mix
the sample and the anticoagulant, or to send the sample to the laboratory immediately.
• Antimalarials, furazolidone (in infants), nitrofurantoin, phenacetin, procarbazine, sulfonamides
(possible false-positive)
• Recent blood transfusion.

EQUIPMENTS:
PATIENT PREPARATION:
• Explain to the patient that this test is used to determine the cause of anemia.
• Tell him that a blood sample will be taken. Explain who will perform the venipuncture and when.
• Reassure him that drawing a blood sample will take less than 3 minutes.
• Explain that he may feel slight discomfort from the tourniquet pressure and the needle puncture.
• Review the patient's drug history for medications that may affect test results. Withhold
antimalarials, furazolidone, nitrofurantoin, phenacetin, procarbazine, and sulfonamides. If these
medications must be continued, note this on the laboratory slip.
• Inform the patient that food or fluids need not be restricted before the test.
NORMAL VALUES:
• A negative test result indicates an absence of Heinz bodies
PROCEDURE:
• Perform a venipuncture, collecting the sample in a 7-mllavender-top tube.
• Resume administration of medications withheld before the test.
IMPLICATIONS OF ABNORMAL RESULTS:
• The presence of Heinz bodies - a positive test result - may indicate an inherited RBC enzyme
deficiency, the presence of unstable hemoglobin, thalassemia, or drug-induced RBC injury. Heinz
bodies may also be present after splenectomy
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
• If a hematoma develops at the venipuncture site, apply warm soaks.
.12. SERUM IRON & TOTAL IRON-BINDING CAPACITY
DEFINITION:
 These tests measure forms of iron storage in the body.
PURPOSE:
 These tests are helpful in the differential diagnosis of anemia, in the assessment of iron deficiency
anemia, and in the evaluation of thalassemia, hemochromatosis, and sideroblastic anemia
INDICATIONS:
 Evaluate iron absorption and ability of the body to deal with infection.
 Evaluate iron deficiency and blood loss.
 Aid in the diagnosis or differentiation of anemias.
 Evaluate iron poisoning and overload in renal dialysis patients.
CONTRAINDICATIONS & INTERFERRING FACTORS:
PRECAUTIONS:
 Do not use anticoagulant like oxalate, citrate, or EDTA, because these binds to iron, so are
unacceptable.
 12 hours of fasting is preferred.
 Water intake is allowed.
 Stop taking the iron-containing supplements before 24 to 48 hours.
EQUIPMENTS:
PATIENT’S PREPARATION:
 Before the test, the person should be on fasting for accurate results. The person should not eat and
drink for 8 hours before the test.
NORMAL VALUES:
 229 – 365 g/Dl or 41.2 – 65.7 mol/L
PROCEDURE:
 A venous serum blood sample (10 mL) is obtained by using a redtop tube.
 Serum should be drawn from a patient fasting in the morning. Circadian rhythm affects the iron
levels, which increase in the morning and decrease in the evening.
IMPLICATIONS OF ABNORMAL RESULTS:
 TIBC decreases in iron deficiency anemias, malignancies of the small intestines, anemia of
infection and chronic disease, and iron neoplasms.
 TIBC increases in hemochromatosis, hemosiderosis, thalassemia, and iron overload.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Resume normal activities.
 Interpret test outcome and monitor appropriately. The combination of low serum iron, high TIBC,
and high transferrin levels indicates iron deficiency. Diagnosis of iron deficiency may lead further
to detection of adenocarcinoma of the gastrointestinal tract, a point that cannot be overemphasized.
A significant minority of patients with megaloblastic anemias (20%–40%) have coexisting iron
deficiency. Megaloblastic anemia can interfere with the interpretation of iron studies; repeat iron
studies 1 to 3 months after folate or vitamin B12 replacement.
.13. SERUM FERRITIN
DEFINITION:
 Your body relies on iron in red blood cells to carry oxygen to all its cells. Without enough iron,
your red blood cells will be unable to supply enough oxygen. However, too much iron isn’t good
for your body either. Both high and low iron levels may indicate a serious underlying problem.
 If your doctor suspects you’re experiencing an iron deficiency or an iron overload, they may order a
ferritin test. This measures the amount of stored iron in your body, which can give your doctor an
overall picture of your iron levels.
PURPOSE:
 The purpose of ferritin test is to know whether you have too much ferritin in your blood or not
enough. This can give your doctor clues about your overall iron levels. The more ferritin in your
blood, the more stored iron your body has.
INDICATIONS:
 Ferritin is the major iron storage protein of the body. Ferritin levels can be used to indirectly
measure how much iron is in the body. Ferritin has the shape of a hollow sphere that permits the
entry of a variable amount of iron for storage (as ferric hydroxide phosphate complexes).
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
EQUIPMENTS:
 Tourniquet
 Syringe
 Alcohol swab
 Dry cotton ball
PATIENT PREPARATION:
 In some instances, your doctor may ask you not to eat for at least 12 hours before your blood is
drawn.
 According to the American Association for Clinical Chemistry (AACC), the test is more accurate
when it’s performed in the morning after you haven’t eaten for a while
NORMAL VALUES:
 For men, 24 to 336 micrograms per liter
 For women, 11 to 307 micrograms per liter
PROCEDURE:
 The ferritin test requires only a small amount of blood to diagnose your ferritin levels accurately.
 A healthcare professional may apply a band around your arm to make your veins more visible.
 After wiping your skin with an antiseptic swab, the provider inserts a small needle into your vein to
obtain a sample. This sample is then sent to a laboratory for analysis.
IMPLICATIONS OF ABNORMAL RESULTS:
 CAUSES OF LOW FERRITIN LEVELS
 A lower-than-normal ferritin level can indicate that you have an iron deficiency, which can
happen when you don’t consume enough iron in your daily diet.
 Another condition that affects iron levels is anemia, which is when you don’t have enough red
blood cells for iron to attach to.
 Additional conditions include:
Excessive menstrual bleeding
Stomach conditions that affect intestinal absorption
Internal bleeding
 CAUSES OF HIGH FERRITIN LEVELS
 Ferritin levels that are too high can indicate certain conditions. One example is
hemochromatosis, which is when your body absorbs too much iron.
 Other conditions that cause high iron levels include:
Rheumatoid arthritis
Hyperthyroidism
Adult-onset still’s disease
Type 2 diabetes
Leukemia
Hodgkin’s lymphoma
Iron poisoning
Frequent blood transfusions
Liver disease, such as chronic hepatitis c
Restless leg syndrome
 The most common causes of elevated ferritin levels are obesity, inflammation, and daily alcohol
intake. The most common causes of genetic-related elevated ferritin levels is the condition
hemochromatosis.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
.14. WHITE BLOOD CELL
DEFINITION:
 A white blood cell (WBC) count is a test that measures the number of white blood cells in your
body. This test is often included with a complete blood count (CBC). The term “white blood cell
count” is also used more generally to refer to the number of white blood cells in your body.
PURPOSE:
 Having a higher or lower number of WBCs than normal may indicate an underlying condition. A
WBC count can detect hidden infections within your body and alert doctors to undiagnosed medical
conditions, such as autoimmune diseases, immune deficiencies, and blood disorders. This test also
helps doctors monitor the effectiveness of chemotherapy or radiation treatment in people with
cancer.
INDICATIONS:
 Indications for a WBC count include infectious and inflammatory diseases
 Leukemia and lymphoma
 Bone marrow disorders
CONTRAINDICATIONS/PRECAUTIONS:
INTERFERRING FACTORS:
 Acute emotional or physical stress can increase WBC counts.
EQUIPMENTS:
 Tourniquet
 Syringe
 Alcohol swab
 Dry cotton ball
PATIENT PREPARATION:
 A WBC count requires no specific preparation. You simply schedule an appointment with your
doctor or set up an appointment at a local medical laboratory.
 Certain medications can interfere with your lab results and either lower or increase your WBC
count. The drugs that may affect your test results include:
 Corticosteroids
 Quinidine
 Heparin
 Clozapine
 Antibiotics
 Antihistamines
 Diuretics
 Anticonvulsants
 Sulfonamides
 Chemotherapy medication
 Prior to having your blood drawn, tell your doctor about all prescription and nonprescription
medications that you’re currently taking.
NORMAL VALUES:
AGE RANGE WBC COUNT (per mcL of blood)
NEWBORN 9,000 – 30,000
CHILDREN UNDER 2 YEARS OLD 6,200 – 17,000
CHILDREN OVER 2 YEARS OLD 5,000 – 10,000
AND ADULTS

NORMAL PERCENTAGE OF
TYPES OF WBC
OVERALL WBC COUNT
NEUTROPHIL 55% – 73%
LYMPHOCYTE 20% – 40%
EOSINOPHIL 1% – 4%
MONOCYTE 2% - 8%
BASOPHIL 0.5% – 1%
PROCEDURE:
 The healthcare provider first cleans the needle site to kill any germs and then ties an elastic band
around the upper section of your arm. This elastic band helps the blood fill your vein, making it
easier for the blood to be drawn.
 The healthcare provider slowly inserts a needle into your arm or hand and collects the blood in an
attached tube.
 The provider then removes the elastic band from around your arm and slowly removes the needle.
 Finally, the technician applies gauze to the needle site to stop the bleeding.
IMPLICATIONS OF ABNORMAL RESULTS:
 Leukopenia is the medical term used to describe a low WBC count. A low number can be triggered
by:
 HIV
 Autoimmune disorders
 Bone marrow disorders or damage
 Lymphoma
 Severe infections
 Liver and spleen diseases
 Lupus
 Radiation therapy
 Some medications, such as antibiotics
 Leukocytosis is the medical term used to describe a high WBC count. This can be triggered by:
 Smoking
 Infections such as tuberculosis
 Tumors in the bone marrow
 Leukemia
 Inflammatory conditions, such as arthritis and bowel disease
 Stress
 Exercise
 Tissue damage
 Pregnancy
 Allergies
 Asthma
 Some medications, such as corticosteroids
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Encourage client to include a good source of protein in the diet, as amino acids found in protein are
needed to build WBCs.
 Vitamins B-12 and folate are also needed to produce WBCs, so consider adding a multivitamin and
mineral supplement daily. Though not proven, some believe that adding vitamin C, vitamin E, zinc,
garlic, selenium, and even spicy foods to your diet can boost the immune system.
 If the patient is being treated for cancer or other causes of leukocytosis, instruct her/him to talk to
his/her doctor before taking any supplements, as they might interfere with treatments.
.15. WHITE BLOOD CELL DIFFERENTIAL
DEFINITION:
 The differential totals the number of each type and determines if the cells are present in normal
proportion to one another, if one cell type is increased or decreased, or if immature cells are
present.
PURPOSE:
 The white blood cell differential is often used as part of a complete blood count (CBC) as a general
health check. It may be used to help diagnose the cause of a high or low white blood cell (WBC)
count, as determined with a CBC. It may also be used to help diagnose and/or monitor other
diseases and conditions that affect one or more different types of WBCs.
INDICATIONS:
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
EQUIPMENTS:
 Tourniquet
 Syringe
 Alcohol swab
 Dry cotton ball
NORMAL VALUES:
NORMAL PERCENTAGE OF
TYPES OF WBC
OVERALL WBC COUNT
NEUTROPHIL 55% – 73%
LYMPHOCYTE 20% – 40%
EOSINOPHIL 1% – 4%
MONOCYTE 2% - 8%
BASOPHIL 0.5% – 1%
BAND (YOUNG NEUTROPHIL) 0 – 3%
PROCEDURE:
 A blood sample is needed.
 A laboratory specialist takes a drop of blood from your sample and smears it onto a glass slide. The
smear is stained with a special dye, which helps tell the difference between various types of white
blood cells.
 A special machine or a health care provider counts the number of each type of cell. The test shows
if the number of cells are in proper proportion with one another, and if there is more or less of one
cell type.
IMPLICATIONS OF ABNORMAL RESULTS:
EXAMPLES OF CAUSES OF EXAMPLES OF CAUSES
TYPE OF WBC
A HIGH COUNT OF A LOW COUNT
NEUTROPHILS (absolute  Known as neutrophilia  Known as neutropenia
neutrophil count, percent  Acute bacterial infections and  Myelodysplastic syndrome
neutrophils) also some infections caused  Severe, overwhelming
by viruses and fungi infection (e.g., sepsis--
 Inflammation (e.g., neutrophils are used up)
inflammatory bowel disease,  Reaction to drugs (e.g.,
rheumatoid arthritis) penicillin, ibuprofen,
 Tissue death (necrosis) phenytoin, etc.)
caused by trauma, major  Autoimmune disorder
surgery, heart attack, burns  Chemotherapy
 Physiological (stress,  Cancer that spreads to the
rigorous exercise) bone marrow
 Smoking  Aplastic anemia
 Pregnancy—last trimester or
during labor
 Chronic leukemia (e.g.,
myelogenous leukemia)
Lymphocytes (Absolute  Known as lymphopenia or
lymphocyte count, percent lymphocytopenia
lymphocytes)  Autoimmune disorders (e.g.,
lupus, rheumatoid arthritis)
 Infections (e.g., HIV, TB,
hepatitis, influenza)
 Bone marrow damage (e.g.,
chemotherapy, radiation
therapy)
 Immune deficiency
Monocytes (Absolute  Known as monocytosis  Known as monocytopenia
monocyte count, percent  Chronic infections (e.g.,  Usually, one low count is
monocytes) tuberculosis, fungal not medically significant.
infection)  Repeated low counts can
 Infection within the heart indicate:
(bacterial endocarditis)  Bone marrow damage or
 Collagen vascular diseases failure
(e.g., lupus, scleroderma,  Hairy-cell leukemia
rheumatoid arthritis,
vasculitis)
 Inflammatory bowel disease
 Monocytic leukemia
 Chronic myelomonocytic
leukemia
 Juvenile myelomonocytic
leukemia
Eosinophils (Absolute  Known as eosinophilia  Known as eosinopenia
eosinophil count, percent  Asthma, allergies such as hay  This is often difficult to
eosinophils) fever determine because
 Drug reactions numbers are normally low
 Inflammation of the skin in the blood. One or an
(e.g., eczema, dermatitis) occasional low number is
usually not medically
 Parasitic infections
significant.
 Inflammatory disorders (e.g.,
celiac disease, inflammatory
bowel disease)
 Certain malignancies/cancers
 Hypereosinophilic myeloid
neoplasms
Basophils (Absolute basophil  Known as basophilia  Known as basopenia
count, percent basophils)  Rare allergic reactions (e.g.,  As with eosinophils,
hives, food allergy) numbers are normally low
 Inflammation (rheumatoid in the blood; usually not
arthritis, ulcerative colitis) medically significant.
 Some leukemias (e.g.,
chronic myeloid leukemia)
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
.16. BLEEDING TIME
DEFINITION:
 In a bleeding time test, it is assessed what the rapidness with which the blood can clot and it can
stop bleeding is. In this test, a small puncture is made in the skin of the person. By performing this
test, it can be easily determined the way in which the platelets work together to form clots.
PURPOSE:
 This determines how quickly your blood clots to stop bleeding. The test is a basic assessment of
how well your blood platelets work to form clots.
INDICATIONS:
 It was used to screen for bleeding disorders and quantify platelet function in patients taking aspirin
or non-steroidal anti-inflammatory medications.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Some examples include aspirin, thrombocytopenia, and uremia. Additional factors include the test
procedure and subjective observation by the performing technician.
EQUIPMENTS:
 Tourniquet
 Syringe
 Alcohol swab
 Dry cotton ball
PATIENT PREPARATION:
 Tell your doctor about any medications you’re taking, including prescriptions, over-the-counter
medicines, and vitamin and mineral supplements. Some medications, such as aspirin, can affect
how well your blood clots.
 Your doctor may instruct you to stop taking your medication a few days before your test. Follow
your doctor’s instructions, but don’t stop taking any medication unless instructed to do so by your
doctor.
 On the day of your test, wear a short-sleeved shirt so that the healthcare provider can easily access
your arm.
NORMAL VALUES:
 The normal bleeding time is between 2-7 minutes. Bleeding time normal range can still be
considered between a one minute to eight minutes.
PROCEDURE:
 They clean the puncture site with an antiseptic to minimize the risk of infection.
 They place a pressure cuff around your upper arm and inflate it.
 Next, they make two small cuts on your lower arm. These will be deep enough to cause slight
bleeding. You might feel a slight scratch when they make the cuts, but the cuts are very shallow and
shouldn’t cause much pain.
 They remove the cuff from your arm.
 Using a stopwatch or timer, they blot the cuts with paper every 30 seconds until the bleeding stops.
They record the time it takes for you to stop bleeding and then bandage the cuts.
IMPLICATIONS OF ABNORMAL RESULTS:
 Abnormal results from a bleeding time test can be a sign that you need more in-depth testing to find
the cause of your prolonged bleeding. It could mean you have an acquired platelet function defect,
which is a condition that develops after birth and affects how well your blood platelets work. Your
body may produce too many or too few platelets, or your platelets may not work properly.
 Abnormal results could also indicate the following conditions:
 A blood vessel defect is any condition that affects how well your blood vessels transport blood
through your body.
 A genetic platelet function defect is a condition present at birth that affects how well your
platelets function. Hemophilia is one example of this type of defect.
 Primary thrombocythemia is a condition in which your bone marrow creates too many platelets.
 Thrombocytopenia is a condition that causes your body to produce too few platelets.
 Von Willebrand’s disease is a hereditary condition that affects how your blood coagulates
(clots).
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
.17. PLATELET COUNT
DEFINITION:
 A platelet blood count is a blood test that measures the average number of platelets in the blood.
PURPOSE:
 A doctor will often perform a platelet count test if they suspect a person has a disorder that affects
platelet count.
INDICATIONS:
 A platelet count may be used:
 To screen for or diagnose various diseases and conditions that can cause problems with blood
clot formation. It may be used as part of the workup of a bleeding disorder, bone marrow
disease, or excessive clotting disorder, to name just a few.
 As a monitoring tool if you have an underlying condition, are being treated for a platelet
disorder, or are undergoing treatment with drugs known to affect platelets.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Exposure to certain viruses, including Epstein-Barr, cytomegalovirus, hepatitis, and HIV.
 An autoimmune disease (the body's immune system attacks the body), such as immune
thrombocytopenic purpura or ITP).
 An enlarged spleen (an organ that acts as a filter for the blood and helps the body fight infection).
EQUIPMENTS:
 Tourniquet
 Syringe
 Alcohol swab
 Dry cotton ball
NORMAL VALUES:
 The ideal platelet range is 150,000 to 400,000 per mcL in most healthy people.
PROCEDURE:
 The test involves drawing blood from a vein in the arm or hand.
 A technician puts the blood sample into a machine that counts the number of platelets and produces
a report of the findings.
IMPLICATIONS OF ABNORMAL RESULTS:
 If a person’s platelet count remains high, the following medical conditions may be responsible:
 CANCER: Lung, stomach, breast, and ovarian cancers, as well as lymphoma, can cause high
platelet counts. Additional blood testing, imaging scans, or a biopsy can test for cancer.
 ANEMIA: People with iron-deficiency or hemolytic anemia may have high platelets. Further
blood testing can detect most forms of anemia.
 INFLAMMATORY DISORDERS: Diseases that cause an inflammatory immune response,
such as rheumatoid arthritis or inflammatory bowel disease (IBD), can increase platelet count.
A person will have other symptoms in most cases.
 INFECTIONS: Some infections, such as tuberculosis, can cause high platelets.
 SPLENECTOMY: Removal of the spleen can cause a temporary increase in platelets.
 Common causes of low platelet volume include:
 VIRUSES: Viruses, such as mononucleosis, HIV, AIDS, measles, and hepatitis may deplete
platelets.
 MEDICATION: Drugs, such as aspirin, H2-blockers, quinidine, antibiotics containing sulfa,
and some diuretics may lower platelet count.
 CANCER: Cancer that has spread to the bone marrow can harm the body’s ability to make new
platelets. Lymphoma and leukemia are common culprits.
 ANEMIA: A type of anemia called aplastic anemia reduces the number of all kinds of blood
cells, including platelets.
 INFECTION: A bacterial infection, especially the blood infection sepsis, can reduce platelet
count.
 AUTOIMMUNE DISORDERS: Autoimmune diseases such as lupus and Crohn’s disease
lower platelet count by causing the body to attack its tissue.
 CHEMOTHERAPY: Chemotherapy harms existing tissue in addition to cancer cells, which can
make it difficult for the body to produce platelets.
 POISONING: Exposure to some pesticides can damage platelets.
 Cirrhosis: Liver cirrhosis, often due to excessive drinking, can reduce platelet count.
 Chronic bleeding: Any disorder that causes ongoing uncontrolled bleeding, such as stomach
ulcers, can deplete platelets.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
.18. CAPILLARY FRAGILITY (TOURNIQUET TEST, RUMPEL-LEEDE CAPILLARY FRAGILITY
TEST)
DEFINITION:
 The capillary fragility test is a test using a blood pressure cuff
PURPOSE:
 The test is a marker of capillary fragility and it can be used as a triage tool to differentiate patients
with acute gastroenteritis, for example, from those with dengue. Even if a tourniquet test was
previously done, it should be repeated if:
 It was previously negative
 There is no bleeding manifestation
INDICATIONS:
 Vitamin C Deficiency
 Thrombocytopenia
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Interfering factors with this test are women who are premenstrual, postmenstrual and not taking
hormones, or those with sun damaged skin, since all will have increased capillary fragility.
EQUIPMENTS:
 Blood Pressure Apparatus
NORMAL VALUES:
 Ten petechiae per square inch is considered normal
PROCEDURE:
 Take the patient's blood pressure and record it, for example, 100/70.
 Inflate the cuff to a point midway between SBP and DBP and maintain for minutes. (100 + 70) ÷ 2 =
85 mm Hg
 Reduce and wait 2 minutes.
 Count petechiae below antecubital fossa.
 A positive test is more than 10 petechiae per 1 square inch.
IMPLICATIONS OF ABNORMAL RESULTS:
 10 or more petechiae indicate capillary fragility, which occurs due to poor platelet function, bleeding
diathesis or thrombocytopenia, and can be seen in cases of scurvy.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
.19. PLATELET AGGREGATION
DEFINITION:
 A platelet aggregation test checks how well your platelets clump together to form blood clots.
Platelets are a type of blood cell. They help form blood clots by sticking together. A clot is what
stops the bleeding when you have a wound. Without platelets, you could bleed to death.
PURPOSE:
 Your doctor my order this test if you’re experiencing symptoms of a bleeding disorder, abnormal
platelet function, or low platelet count. Symptoms may include:
 Excessive bleeding
 Excessive bruising
 Bleeding from the nose or gums
 Excessive menstrual bleeding
 Blood in the urine or stool
 Your doctor may also order this test if you have a family history of bleeding problems.
 The results of this test can help your doctor figure out the cause of bleeding problems. It can also
help diagnose:
 An autoimmune disorder (such as systemic lupus erythematosus)
 Genetic disorders (including bernard-soulier syndrome, von willebrand disease, glanzmann’s
thrombasthenia, or platelet storage pool disease)
 Medication side effects (that affect platelet function)
 Myeloproliferative disorders (such as certain types of leukemia)
 uremia (a condition caused by significant kidney disease)
INDICATIONS:
 Indications for platelet aggregation studies include the following: Diagnostic evaluation of excessive
bleeding or bruising. Monitor the effectiveness of antiplatelet medication. Detect aspirin resistance.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Some examples include aspirin, thrombocytopenia, and uremia. Additional factors include the test
procedure and subjective observation by the performing technician.
EQUIPMENTS:
PATIENT PREPARATION:
 Unless you’re told otherwise, you can eat and drink before this test.
 You may schedule it at any time during the day, unless your doctor specifies otherwise.
 You shouldn’t exercise 20 minutes before your test.
 Inform your doctor of everything you’re taking, including over-the-counter and prescription drugs.
Your doctor will tell you if you should stop taking a drug or change the dosage before your test.
NORMAL VALUES:
 The reference range is a normal biphasic pattern of aggregation in response to specific platelet
activators
PROCEDURE:
 To begin, the healthcare provider will put on gloves and clean the area around your vein. Blood is
usually drawn from a vein on the front of the arm near the elbow crease or the back of the hand.
 Next, the healthcare provider will tie an elastic band around your upper arm. This helps the blood
pool in your vein. It makes it easier for the technician to draw blood.
 The healthcare provider will insert a sterile needle into your vein and draw blood. You may
experience mild to moderate pain while they’re inserting the needle or drawing the blood. It may feel
like a pricking or burning sensation. Relaxing your arm can help reduce the pain.
 When the healthcare provider is done, they’ll remove the needle and apply pressure to the puncture
to stop bleeding. You should keep pressure on the area to prevent bruising.
 Your blood sample will be sent off to a laboratory for testing.
IMPLICATIONS OF ABNORMAL RESULTS:
 Decreased platelet aggregation may be due to:
 Autoimmune disorders that produce antibodies against platelets
 Bernard-Soulier syndrome
 Fibrin degradation products
 Glanzmann's thrombasthenia
 Medicines that block platelet formation
 Myeloproliferative disorders
 Storage pool disease
 Uremia (a result of kidney failure)
 Von Willebrand's disease
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
.20. ACTIVATED PARTIAL PROTHROMBIN TIME
DEFINITION:
 The partial thromboplastin time (PTT; also known as activated partial thromboplastin time (aPTT))
is a screening test that helps evaluate a person's ability to appropriately form blood clots. It
measures the number of seconds it takes for a clot to form in a sample of blood after substances
(reagents) are added. The PTT assesses the amount and the function of certain proteins in the blood
called coagulation or clotting factors that are an important part of blood clot formation.
PURPOSE:
 To identify coagulation factor deficiency; if the PTT is prolonged, further studies can then be
performed to identify what coagulation factors may be deficient or dysfunctional, or to determine if
an antibody against a coagulation factor (known as a factor-specific inhibitor) is present in the
blood.
 To detect nonspecific autoantibodies (antiphospholipid antibodies), such as lupus anticoagulant; these are
associated with clotting episodes and with recurrent miscarriages. For this reason, PTT testing may
be performed as part of a clotting disorder panel to help investigate recurrent miscarriages or
diagnose antiphospholipid syndrome (APS). A variation of the PTT called the LA-sensitive PTT may be
used for this purpose.
 To monitor standard (unfractionated, UF) heparin anticoagulant therapy; however, some labs now
use the anti-Xa test to monitor heparin therapy. Heparin is an anticoagulation drug that is given
intravenously (IV) or by injection to prevent and to treat blood clots ( embolism and thromboembolism).
It prolongs PTT. When heparin is administered for therapeutic purposes, it must be closely
monitored. If too much is given, the treated person may bleed excessively; with too little, the
treated person may continue to clot.
 Based on carefully obtained patient histories, the PTT and PT are sometimes selectively performed
before a scheduled surgery or other invasive procedures to screen for potential bleeding tendencies.
INDICATIONS:
 When you have unexplained bleeding
 Inappropriate blood clotting
 Recurrent miscarriages
 Sometimes when you are on standard heparin anticoagulant therapy
 Sometimes before a scheduled surgery
CONTRAINDICATIONS/PRECAUTIONS:
INTERFERRING FACTORS:
 Drugs that may prolong the test values, including antihistamines, ascorbic acid, chlorpromazine,
heparin, and salicylates.
 Incorrect blood-to-citrate ratio.
 Hematocrit that is highly increased or decreased
EQUIPMENTS:
PATIENT PREPARATION:
 None, however, a high-fat meal prior to the blood draw may interfere with the test and should be
avoided.
NORMAL VALUES:
 A typical aPTT value is 30 to 40 seconds
PROCEDURE:
 To perform the test, the phlebotomist or nurse takes a sample of blood from your arm. They clean
the site with an alcohol swab and insert a needle into your vein.
 A tube attached to the needle collects the blood. After collecting enough blood, they remove the
needle and cover the puncture site with a gauze pad.
 The lab technician adds chemicals to this blood sample and measures the number of seconds it
takes for the sample to clot.
IMPLICATIONS OF ABNORMAL RESULTS:
COMMON CONDITION
PT RESULT PTT RESULT
PRESENT
 Liver disease, vitamin K
deficiency, decreased or
defective factor VII,
chronic DIC, warfarin or
PROLONGED NORMAL
other vitamin K
antagonist (e.g.,
brodifacoum in some
cannabinoids)
 Hemophilia A or B
(decreased or defective
factor VIII or IX) or
factor XI deficiency, von
NORMAL PROLONGED
Willebrand disease
(severe form), factor XII
deficiency, or lupus
anticoagulant present
 Decreased or defective
factor I (fibrinogen), II
PROLONGED PROLONGED (prothrombin), V or X,
severe liver disease,
acute DIC
 May indicate normal
hemostasis; however, PT
and PTT can be normal
in conditions such as
mild deficiencies in
NORMAL OR SLIGHTLY
NORMAL other factors and mild
PROLONGED
form of von Willebrand
disease. Further testing
may be required to
diagnose these
conditions.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
.21. PROTHROMBIN TIME
DEFINITION:
 Prothrombin time (PT) is a blood test that measures how long it takes blood to clot .
PURPOSE:
 A prothrombin time test can be used to check for bleeding problems. PT is also used to check
whether medicine to prevent blood clots is working.
INDICATIONS:
 Conduct a PT screen for prothrombin deficiency and evaluate heparin and Coumadin effects, liver
failure and vitamin K deficiency
 Investigate symptoms of easy bruising, petechiae, gastrointestinal bleeding, nosebleeds and heavy
menstrual flow.
 Evaluate disseminated intravascular coagulation.
CONTRAINDICATIONS/PRECAUTIONS:
INTERFERRING FACTORS:
 Warfarin use.
 Vitamin K deficiency from malnutrition, biliary obstruction, malabsorption syndromes, or use of
antibiotics.
 Certain foods, such as beef and pork liver, green tea, broccoli, chickpeas, kale, turnip greens, and
soybean products contain large amounts of vitamin K
EQUIPMENTS:
PATIENT PREPARATION:
 None needed, although if you are receiving anticoagulant therapy, the blood sample should be
collected before taking your daily dose.
NORMAL VALUES:
 PT is measured in seconds. Most of the time, results are given as what is called INR (international
normalized ratio). If you are not taking blood thinning medicines, such as warfarin, the normal
range for your PT results is: 11 to 13.5 seconds.
PROCEDURE:
 A sample of the patient's blood is obtained by venipuncture.
 The blood is decalcified (by collecting it into a tube with oxalate or citrate ions) to prevent the
clotting process from starting before the test.
 The blood cells are separated from the liquid part of blood (plasma) by centrifugation.
IMPLICATIONS OF ABNORMAL RESULTS:
 CLOTTING TOO SLOW
 Blood that clots too slowly can be caused by:
Blood-thinning medications
Liver problems
Inadequate levels of proteins that cause blood to clot
Vitamin K deficiency
Other substances in your blood that hinder the work of clotting factors
 CLOTTING TOO FAST
 Blood that clots too quickly can be caused by:
Supplements that contain vitamin K
High intake of foods that contain vitamin K, such as liver, broccoli, chickpeas, green tea,
kale, turnip greens and products that contain soybeans
Estrogen-containing medications, such as birth control pills and hormone replacement
therapy
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
.22. ONE-STAGE FACTOR ASSAY: EXTRINSIC COAGULATION SYSTEM
DEFINITION:
 Intrinsic coagulation system consists of the protein factors XII, XI, IX and VIII and prekallikrein
(PK) and high molecular weight kininogen (HK). The APTT assess the coagulation proteins of the
so-called intrinsic system and common pathways. This assay is commonly referred to as the partial
thromboplastin time (PTT) but it is really an “activated” PTT in that its reagent contains a
negatively charged surface that accelerates the rate of the reaction
PURPOSE:
 Used to discriminate among mild, moderate, and severe deficiencies and to follow the course of
acquired factor inhibitors.
INDICATIONS:
 Prolonged PT or PTT of unknown etiology:
 If the PT is prolonged but the PTT is normal, factors of the extrinsic pathway are evaluated (i.e.,
factors, II, V, VII, and X).
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Therapy with anticoagulants and other drugs known to alter hemostasis
 Traumatic venipunctures and excessive agitation of the sample may alter test results
EQUIPMENTS:
PATIENT PREPARATION:
 Client preparation is the same as that for any study involving the collection of a peripheral blood
sample
 If the individual is receiving anticoagulant therapy, the time and the amount of the last dose should
be noted.
NORMAL VALUES:
 Extrinsic Pathway
 Factor II 70–130 mg/100 mL 0.7–1.3 U
 Factor V 70–130 mg/100 mL 0.7–1.3 U
 Factor VII 70–150 mg/100 mL 0.7–1.5 U
 Factor X 70–130 mg/100 mL 0.7–1.3 U
PROCEDURE:
 For assays of the factors involved in the intrinsic and extrinsic coagulation pathways, a
venipuncture is performed and the sample collected in a light-blue topped tube. For factor XIII
assays, the sample is collected in a red-topped tube. As with other coagulation studies, traumatic
venipunctures and excessive agitation of the sample should be avoided. The samples should be sent
to the laboratory immediately.
IMPLICATIONS OF ABNORMAL RESULTS:
 An abnormality in the extrinsic or common pathways can result in a significant bleeding tendency.
Inherited deficiencies of a single coagulation factor, including factors VII, V, X, and prothrombin,
are rare. More commonly, bleeding results from acquired deficiencies in several factors.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Care and assessment after the procedure are essentially the same as for any study involving the
collection of a peripheral blood sample. Because the client may have a coagulation deficiency,
maintain digital pressure directly on the puncture site for 3 to 5 minutes after the needle is
withdrawn. Inspect the site for excessive bruising after the procedure.
.23. ONE-STAGE FACTOR ASSAY: INTRINSIC COAGULATION SYSTEM
DEFINITION:
 Intrinsic coagulation system consists of the protein factors XII, XI, IX and VIII and prekallikrein
(PK) and high molecular weight kininogen (HK). The APTT assess the coagulation proteins of the
so-called intrinsic system and common pathways. This assay is commonly referred to as the partial
thromboplastin time (PTT) but it is really an “activated” PTT in that its reagent contains a
negatively charged surface that accelerates the rate of the reaction
PURPOSE:
INDICATIONS:
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
EQUIPMENTS
NORMAL VALUES:
PROCEDURE:
 For these procedures, obtain 7 mL of venous blood, using a light blue-top Vacutainer tube (sodium
citrate as anticoagulant) and mixing gently.
IMPLICATIONS OF ABNORMAL RESULTS:
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Evaluate outcomes and counsel the patient appropriately about the treatment (adjustment of
dosage).
 Assess for bleeding when the times are prolonged or increased.
 Examine skin for bruises on extremities and on parts of the body the patient cannot easily see.
 Record bleeding from the venipuncture and injection sites, nose, or groin.
.24. PLASMA THROMBIN TIME
DEFINITION:
 Thrombin is an enzyme that functions in the release of fibrin from fibrinogen in the final stage of
the clotting cascade. This test measures the clotting time of a sample of plasma to which thrombin
has been added. Thrombin time is longer than normal when abnormalities in the conversion of
fibrinogen into fibrin are present.
PURPOSE:
 To detect a fibrinogen deficiency or defect
 To help diagnose DIC and hepatic disease
 To monitor the effectiveness of heparin or thrombolytic agents
INDICATIONS:
 The test is used as a rapid screening device to detect profound fibrinogen deficiency.
 This test is not reliable to monitor heparin therapy in clients with DIC.
 This test will NOT differentiate primary fibrinolysis from DIC
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Hemolyzed specimens invalidate the results.
 Failure to discard the first 1-2 mL of blood may result in specimen contamination with tissue
thromboplastin.
 Heparin therapy within 2 days before the test increases the results. Collecting a sample from a
heparinized line without discarding the first blood withdrawn can falsely prolong results.
 A recent blood or plasma transfusion will invalidate the results.
EQUIPMENTS:
 Tube: 2.7-mL blue topped or 4.5-mL blue topped tube and a control tube, and a waste tube or
syringe.
NORMAL VALUES:
 Within 2 seconds of 9-second to 13-second control value; or within 5 seconds of 15-second to 20-
second control value; or <1.5 times control value
PROCEDURE:
 Withdraw 2 mL of blood into a syringe or vacuum tube. Remove the syringe or tube, leaving the
needle in place. (From a heparinized line, discard an amount equal to the volume of the tubing
prime.) Attach a second syringe, and draw a blood sample volume of 2.4 mL for a 2.7-mL tube and
4.0 mL for a 4.5-mL tube.
 Gently tilt the tube five or six times to mix the sample.
IMPLICATIONS OF ABNORMAL RESULTS:
 Prolonged plasma thrombin time:
 Heparin therapy
 Hepatic disease
 DIC
 Hypofibrinogenemia
 Dysfibrinogenemia
 Acute leukemia
 Lymphoma
 Factor deficiency
 Shock
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Send the sample to the laboratory within 2 hours.
 Refrigerate the sample. The plasma should be frozen if it is not tested promptly.
.25. PLASMA FIBRINOGEN QUANTITATION
DEFINITION:
 Fibrinogen (factor I) is heat-stable, complex polypeptide that converts to the insoluble polymer of
fibrin after thrombin enzymatic action and combines with platelets to clot the blood. Synthesized in
the liver, fibrinogen increases in diseases associated with tissue damage or inflammation. There is
some evidence that it may be useful as a predictor of arteriosclerotic disease. One performs this test
by adding thrombin to the client’s plasma and measuring the amount of time taken for clotting to
occur at standard dilutions. The amount of fibrin is then calculated based on the thrombin clotting
time.
PURPOSE:
 To evaluate fibrinolytic activity as well as identity congenital deficiency, disseminated
intravascular coagulation, and severe liver disease.
INDICATIONS:
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Reject hemolyzed specimens or tubes partially filled with blood.
EQUIPMENTS:
 Tube: 2.7- or 4.5-mL blue topped
NORMAL VALUES:
 Quantitative is 200-400 mg/dL (2.04.0 g/L, SI units).
 Lower values can occur in newborns.
PROCEDURE:
 Withdraw 2mL of blood into a syringe or vacuum tube. Remove the syringe or tube, leaving the
needle in place. Attach a second syringe and draw two blood samples, one in a citrated blue topped
tube and the other in control tube. The sample quantity should be 2.4mL for a 2.7-mL tube and 4.0
mL for a 4.5-mL tube. Draw a 5-mL blood sample in a sodium citrate anticoagulated blue topped
tube.
IMPLICATIONS OF ABNORMAL RESULTS:
 High fibrinogen values may also be associated with:
 Infections and inflammation
 Cancer
 Rheumatoid arthritis
 Nephrotic syndrome
 Heart attack
 Stroke
 Pregnancy 
 Low fibrinogen values may be associated with:
 Liver disease
 DIC
 Cancer
 Malnutrition
 Inherited or congenital blood clotting disorders
 Frequent blood transfusions
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 For clients with coagulopathy, hold pressure over sampling site for at least 5 minutes and observe
site closely for development of a hematoma.
 Transport the specimens to the laboratory immediately for spinning. The specimens are then stable
for 3 days when refrigerated.
.26. FIBRIN SPLIT PRODUCTS OR FIBRINOGEN DEGRADATION PRODUCTS (FDP)
DEFINITION:
 Fibrinogen degradation products is a test that directly measures the effectiveness of the clotting
process. There are four products (i.e., D, E, X, Y) that are form during the dissolving of clots. These
substances are indicative of recent clotting activity. If present in an increased amount, they act as
anticoagulants.
PURPOSE:
INDICATIONS:
 Elevated levels are found with blood transfusion reactions, thromboembolic states, cancer, DVT,
preeclampsia, sepsis, shock, sunstroke, and extensive tissue damage.
 Decreased level are not significant
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Traumatic venipuncture
 Medications that alter results are barbiturates, heparin, urokinase, and streptokinase.
EQUIPMENTS:
 Blue-top tubes
 Needle and syringe or vacutainer
 Alcohol swab
NORMAL VALUES:
 <10 mg/mL or <10mg/L (SI units)
PROCEDURE:
 Label the specimen tube. Correctly identifies the client and the test to be performed.
 Obtain a 2mL blood sample.
 Do not agitate the tube. Agitation may cause RBC hemolysis
 Send tube to the laboratory.
IMPLICATIONS OF ABNORMAL RESULTS:
 Increased FDPs may be a sign of primary or secondary fibrinolysis (clot-dissolving activity) due to
a variety of causes, including:
 Blood clotting problems
 Burns
 Problem with the heart's structure and function that is present at birth (congenital heart disease)
 Disseminated intravascular coagulation (DIC)
 Low level of oxygen in the blood
 Infections
 Leukemia
 Liver disease
 Problem during pregnancy such as preeclampsia, placenta abruptio, miscarriage
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Apply pressure for prolonged time (5mins) to the venipuncture site.
 Explain that some bruising, discomfort, and swelling may appear at the site and that warm, moist
compresses can alleviate this.
 Monitor for signs of infection.
.27. PLASMA PLASMINOGEN
DEFINITION:
 Fibrinogen degradation products is a test that directly measures the effectiveness of the clotting
process. There are four products (i.e., D, E, X, Y) that are form during the dissolving of clots. These
substances are indicative of recent clotting activity. If present in an increased amount, they act as
anticoagulants.
PURPOSE:
INDICATIONS:
 Elevated levels are found with blood transfusion reactions, thromboembolic states, cancer, DVT,
preeclampsia, sepsis, shock, sunstroke, and extensive tissue damage.
 Decreased level are not significant
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Traumatic venipuncture
 Medications that alter results are barbiturates, heparin, urokinase, and streptokinase.
EQUIPMENTS:
 Blue-top tubes
 Needle and syringe or vacutainer
 Alcohol swab
NORMAL VALUES:
 <10 mg/mL or <10mg/L (SI units)
PROCEDURE:
 Label the specimen tube. Correctly identifies the client and the test to be performed.
 Obtain a 2mL blood sample.
 Do not agitate the tube. Agitation may cause RBC hemolysis
 Send tube to the laboratory.
IMPLICATIONS OF ABNORMAL RESULTS:
 Increased FDPs may be a sign of primary or secondary fibrinolysis (clot-dissolving activity) due to
a variety of causes, including:
 Blood clotting problems
 Burns
 Problem with the heart's structure and function that is present at birth (congenital heart disease)
 Disseminated intravascular coagulation (DIC)
 Low level of oxygen in the blood
 Infections
 Leukemia
 Liver disease
 Problem during pregnancy such as preeclampsia, placenta abruptio, miscarriage
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Apply pressure for prolonged time (5mins) to the venipuncture site.
 Explain that some bruising, discomfort, and swelling may appear at the site and that warm, moist
compresses can alleviate this.
 Monitor for signs of infection.
e.28. PROTEIN C
DEFINITION:
 Activated protein C is a plasma, vitamin K–dependent glycoprotein anticoagulant that inhibits
factors V and XIII. Protein C was first identified in the early 1980s. Sixty percent of protein C is
bound to complement protein, and it is converted to an activated functional form by active serine
protease and its activity is enhanced by cofactor protein S. Protein C deficiency may be congenital
or acquired. Congenital protein C deficiency is an inherited, autosomal dominant thrombophilia
present in 3%-5% of clients with venous thrombosis. Congenital deficiency may be exhibited either
as reduced protein C levels or as resistance to protein C despite normal levels. Clients with
homozygous deficiencies usually die as a result of thrombosis during their first year of life, which is
often preceded by neonatal purpura fulminans. Those with heterozygous deficiency often have
venous thromboembolisms, such as deep vein thrombosis or pulmonary embolism, at a young age.
Acquired protein C deficiency is seen in acute respiratory distress syndrome, disseminated
intravascular coagulation, hemolytic uremic syndrome, hepatic disease, infection, postoperative
states, vitamin K deficiency, and clients receiving warfarin sodium (Coumadin). Protein C
deficiency is responsible for a much greater proportion of venous thromboses than arterial
thromboses. The factor V Leiden mutation, newly identified in the 1990s, is a thrombotic molecular
defect in factor V making it resistant to anticoagulant activation by protein C. It is a significant
cause of deep vein thrombosis, as the mutation is thought to be present in 5% of the population. The
Leiden mutation is identified by performing an activated protein C resistance test (APTT with and
without commercially available activated protein C) and confirming an abnormal result with DNA
evaluation for the Leiden mutation.
PURPOSE:
 Diagnose the cause of thrombosis. Protein C/protein S ratio is helpful in identifying carriers of
congenital protein C deficiency.
INDICATIONS:
 Elevated levels are found with bacterial infections, active rheumatic fever, postoperative wound
infections, kidney or bone marrow transplant rejection, Chron’s disease, systemic lupus
erythematosus, active rheumatoid arthritis, TB, acute myocardial infarctions, and blood transfusions
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Reject hemolyzed or clotted specimens, specimens not completely mixed, tubes partially filled with
blood, specimens not refrigerated, specimens diluted or contaminated with heparin, or specimens
received more than 2 hours after collection.
 Specimen results are invalidated if client is receiving a recently adjusted (within previous week)
dose of warfarin. Oral anticoagulants decrease functional protein C values.
 Falsely decreased functional protein C values occur in clients with abnormally high levels of factor
VIII.
 Falsely increased functional protein C values occur in clients receiving heparin.
EQUIPMENTS:
 Tube: 4.5-mL blue topped. Also obtain ice.
PATIENT PREPARATION:
 Indicate on the laboratory requisition if the activated protein C resistance testing is needed.
 For recurrent venous thrombosis, perform test at least 2 months after the last event, and with
anticoagulants held.
NORMAL VALUES:
 Critical value <50%
 Heterozygous protein C 20%-74% deficiency
 Homozygous protein C As low as 0% deficiency protein C
PROCEDURE:
 Withdraw 2 mL of blood into a syringe or vacuum tube. Remove the syringe or tube, leaving the
needle in place. Attach a second syringe, and draw a 2.4-mL sample in a 2.7-mL tube or a 4.0-mL
sample in a 4.5-mL tube. Place the specimens immediately into a container of ice.
 Gently tilt the tube five or six times to mix.
IMPLICATIONS OF ABNORMAL RESULTS:
 Increased:
 Diabetes, nephrotic syndrome, pregnancy.
 Drugs include oral contraceptives.
 Decreased:
 Congenital protein C deficiency.
 Acquired protein C deficiency conditions such as disseminated intravascular coagulation,
hepatic disease, vitamin K deficiency.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Place the specimens on ice immediately.
 For clients with coagulopathy, hold pressure over the sampling site for at least 5 minutes and
observe the site closely for development of a hematoma.
 Write the collection time on the laboratory requisition.
 Transport the specimens to the laboratory immediately, discard the ice, and refrigerate the
specimens.
.29. EUGLOBULIN LYSIS TIME
DEFINITION:
 Euglobulin lysis time measures the clotting activities by evaluating plasminogen and plasminogen
activator. These substances are proteins that prevent fibrin clot formations. Fibrinolysis is essential
to normal hemostasis and clotting/dissolution is constantly occurring. When this system is
dysfunctioning, a fibrin clot will dissolve immediately and result in bleeding tendency. The effects
of thrombolytic medications (e.g., streptokinase or urikinase) are assessed by euglobulin testing. In
this test, the lysis time is evaluated by adding the client’s plasma to a blood clot and observed for
6-24 hour (labeled the euglobulin lysis time)
PURPOSE:
 Standard screening test for hyperfibrinolysis
INDICATIONS:
 Elevated levels are found with cirrhosis, shock, DIC, incompatible drug transfusion, malignancies,
and thrombolytic medications.
 Decreased levels are found with prematurity and diabetes.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Exercising within 1 hour of test.
 Venipuncture that is preceded by pumping the fist or massaging the vein
 Anticoagulants
EQUIPMENTS:
 Three blue-top tubes
 Needle and syringe or vacutainer
 Alcohol swab
 Ice
NORMAL VALUES:
 Lysis in 1.5-4 hr
PROCEDURE:
 Label the specimen tube. Correctly identifies the client and the test to be performed.
 Obtain three 2.4 mL samples in three tubes
 Do not agitate the tube. Agitation may cause RBC hemolysis
 Send tube to the laboratory.
 Keep specimen on ice. High temperature alters the results.
IMPLICATIONS OF ABNORMAL RESULTS:
 Longer-than-normal ELT time may be due to:
 Diabetes
 Prematurity
 A shorter-than-normal ELT time may be due to:
 Blood vessel injury or surgery
 Cancer of the prostate
 Cirrhosis
 Fibrinogen deficiency
 Leukemia
 Pregnancy complications (for example, antepartum hemorrhage, hydatidiform mole, amniotic
embolism)
 Shock
 Thrombocytopenia purpura
 The test may also be done to diagnose or rule out:
 Spontaneous abortion
 Primary thrombocythemia
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Apply pressure to the venipuncture site. (Note: may need to leave pressure on 3-5 minutes if there
is prolonged clotting time)
 Explain that some bruising, discomfort, and swelling may appear at the site and that warm, moist
compresses can alleviate this.
 Monitor for signs of infection.
F. MCV/MCH/MCHC
DEFINITION:
 MCH is the content (weight) of hemoglobin (Hb) of the average red cell, or, in other words, a reflection of
hemoglobin mass in red cells.
 Mean corpuscular hemoglobin concentration (MCHC), is the average concentration of hemoglobin in a
given volume of packed red blood cells.
 MCH, MCHC, and MCV are parts of red cell indices (parameters reflecting size and hemoglobin content
of red cells) that have traditionally been used to aid in the differential diagnosis of anemia.
PURPOSE:
 Useful in elucidating the etiology of anemia
 To classify anemia as microcytic, macrocytic and normocytic, hypochromic and nomochronic
INDICATIONS:
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 MCHC
 High values may occur in newborns and infants.
 Presence of leukemia or cold agglutinins may increase levels. MCHC is falsely elevated with a high
blood concentration of heparin.
 MCH
 Hyperlipidemia and high heparin concentrations falsely elevate MCH values.
 WBC counts greater than 50,000/mm3 falsely elevate Hgb and MCH values.
EQUIPMENTS:
NORMAL VALUES:
 MCV: 82–98 mm3 or 82–98 fL (femtoliters)
 MCH: 26–34 pg/cell or 0.40–0.53 fmol/cell (femtomoles)
 MCHC: 32–36 g/dL or 320–360 g/L
PROCEDURE:
 Venous plasma (5–7 mL) with EDTA additive is obtained by venipuncture, using a purple-top Vacutainer
tube. The blood cannot have any clots present for the CBC to be valid.
IMPLICATIONS OF ABNORMAL RESULTS:
 Mean corpuscular volume (MCV) changes in certain conditions. Microcytic RBCs and an MCV less than
80 mm3 (80 fL) occur with iron deficiency, excessive iron requirements, pyridoxineresponse anemia,
thalassemia, lead poisoning, and chronic inflammation. Normocytic RBCs and an MCV of 82 to 98 mm3
(82–98 fL) occur after hemorrhage, hemolytic anemia, and anemias due to inadequate blood formation.
Macrocytic RBCs, with a MCV of more than 98 mm3 (98 fL), occur in some anemias: vitamin B12
deficiency, pernicious anemia, folic acid deficiency in pregnancy and inflammation, fish and tapeworm
infestation, liver disease, alcohol intoxication, after total gastrectomy, and strict vegetarianism.
 Mean corpuscular hemoglobin concentration (MCHC) decreases signify that RBCs contain less
hemoglobin than normal, as in iron deficiency microcytic anemias, chronic blood loss anemia, pyridoxine-
responsive anemia, and thalassemia. • MCHC increases indicate spherocytosis.
 Mean corpuscular hemoglobin (MCH) decreases in microcytic anemia
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
G. DIRECT/INDIRECT COOMB’S TEST
DEFINITION:
 The Coombs’test shows the presence of antigen-antibody complexes. The direct Coombs’ test detects
antigen-antibody complexes on the RBC membrane and RBC sensitization. The indirect Coombs’ test
detects serum antibodies, reveals maternal anti-Rh antibodies during pregnancy, and can detect
incompatibilities not found by other methods.
PURPOSE:
 To detect antibodies that act against the surface of red blood cell
INDICATIONS:
 Diagnose hemolytic disease of the newborn when the RBCs of the infant are sensitized.
 Diagnose acquired hemolytic anemia in adults (ie, autosensitization in vivo).
 Investigate transfusion reaction when the patient may have received incompatible blood that sensitized his
or her own red blood cells.
 Detect drug-induced hemolytic anemia.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Reject hemolyzed specimens.
 Cord blood contaminated by Wharton’s jelly may yield unreliable results.
 Cold agglutinins may cause false-positive results.
 Drugs that may cause false-negative results in the presence of acquired hemolytic anemia include heparin
calcium and heparin sodium.
EQUIPMENTS:
 Tube: Lavender topped, red topped, red/ gray topped, or gold topped.
NORMAL VALUES:
 Direct Coombs’test: No agglutination
 Indirect Coombs’test: No agglutination
PROCEDURE:
 A 7-mL venous blood sample with added EDTA and 20 mL of clotted blood are studied.
 Notify the laboratory about the diagnosis, history of recent and past transfusions, pregnancy, and any drug
therapy.
IMPLICATIONS OF ABNORMAL RESULTS:
 Direct Coombs’test is positive (1+to 4+) in the presence of transfusion reactions; autoimmune hemolytic
anemia (most cases); cephalothin therapy (75% of cases); drugs such as alphamethyldopa (Aldomet),
penicillin and insulin therapy; hemolytic disease of newborn; paroxysmal cold hemoglobinuria (PCH); and
cold agglutinin syndrome.
 Direct Coombs’test is negative in non-autoimmune hemolytic anemias.
 Indirect Coombs’test is positive (1+to 4+) in the presence of specific antibodies, usually from a previous
transfusion or pregnancy, and nonspecific antibodies, as in cold agglutinants.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Interpret the test outcome and counsel the patient appropriately. Hemolytic disease of newborn can occur
when mother is Rh negative and the fetus is Rh positive. The diagnosis is derived from the following
information: The mother is Rh negative, the newborn is Rh positive, and the direct Coombs’test is positive.
Newborn jaundice results from Rh incompatibility. More often, the jaundice results from an ABO
incompatibility.
H. MYOGLOBIN TEST
DEFINITION:
 Myoglobin (Mb, S-Mgb) is an oxyegen binding protein found in striated muscle. It releases oxygen at very
low tensions. Any injury to skeletal muscle will cause a release of myoglobin into the blood. Because
myoglobin rises and falls so rapidly, its use in diagnosing AMI is limited
PURPOSE:
 In combination with other tests, helps diagnose myocardial ischemia; serial values are used to monitor for
reinfarct, success of thrombolytic treatment and myocardial injury during open-heart surgery.
INDICATIONS:
 Early evaluation of a patient with suspected acute myocardial infarction (MI).
 Disease or injury of skeletal muscle - used to assist in the diagnosis
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 It has a very short half-life of 10 minutes in blood and is rapidly cleared by the kidneys. As an index of
myocardial infarct, myoglobin returns rapidly to baseline levels.
 It is known for its excellent clinical sensitivity early after MI but is not a widely used test due to its lack of
tissue specificity.
 Myoglobin levels may be increased after intramuscular injections and have been reported after a high-
voltage electrical accident.
EQUIPMENTS:
 Tube: Red, green, lavender, or pink topped.
PATIENT PREPARATION:
 Clients should have no isotopes 7 days before testing.
NORMAL VALUES:
 Males: 28–72 ng/mL
 Females: 25–58 ng/mL
PROCEDURE:
 Draw a 2-mL blood sample.
IMPLICATIONS OF ABNORMAL RESULTS:
 Higher results may also be caused by:
 Kidney failure
 Shock
 Electrical shock
 Malignant hyperthermia, an inherited condition in which your body temperature rises rapidly and
your muscles contract when you have general anesthesia
 Lower results may mean:
 Rheumatoid arthritis
 Myasthenia gravis
 Antibodies to myoglobin in your blood
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
  Specimens should be refrigerated.
  Specimens may be frozen and stored for up to 2 years.
I. BLOOD TYPING
DEFINITION:
 Blood typing involves determining the four major blood types (A, B, AB, and O). Red blood cells have A,
B, AB, or no (O) surface antigens. These antigens are capable of producing antibodies. These antigens are
capable of producing antibodies. Genes determine the presence or absence of A or B antigens on
chromosome 9. Red blood cells that are known as A have antibodies, while red blood cells B have anti-A
antibodies, red cells A/B have neither antibodies and type O have both, making AB the universal recipient
and O the universal donor. Most anti-A and anti-B antibodies reside in the IgM class of immunoglobulins
and some activity rest with IgG. Anti-A and anti-B antibodies are strong agglutinins causing rapid
complement mediated destruction of incompatible cells. This clumping may plug small vessels and
arterioles as well as accelerated red cell destruction and phagocytosis. With red cell hemolysis there is a
release of free hemoglobin into the bloodstream, which can damage renal tubules and result in renal failure
and death. ABO typing is an agglutination test where red cells are mixed with anti-A and anti-B serum
(forward grouping). The antibody screen detects the antibodies in the serum of donors and recipients which
may lead to transfusion reaction and destruction of red blood cells.
PURPOSE:
 Blood transfusion therapy, erythroblastosis fetalis, paternity determinations, pregnancy, and
preoperatively.
INDICATIONS:
 Evaluates blood type in rape trauma investigations
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Previous administration of incompatible blood; hemolysis of specimen; type and cross-match not done in a
timely fashion (must be done within 48 hour of blood draw); medications that alter results are dextran,
blood or blood products, and IV contrast materials; hemodialysis; improper identification of client or blood
specimen
EQUIPMENTS:
 Red-top tube or lavender-top tube or plasma separator tube; needle and syringe or vacutainer; alcohol
swab; blood bank arm band; labeling material
PATIENT PREPARATION:
 Note the client’s age, medications, past transfusions of blood products, and number of pregnancies on the
laboratory requisition.
 Consult institutional protocol for any additional requirements.
 Do NOT draw specimens during hemodialysis.
NORMAL VALUES:
 Determination of correct blood type
PROCEDURE:
 Identify the client by name, social security number, and hospital number.
 Correctly identifies the client and the test to be performed.
 Obtain a 20-mL blood sample and place 10-mL in red-top tube and 10mL in lavender-top tube.
 Label specimen with client’s name, social security number, and hospital number and assign a blood bank
number and place a blood bank wrist band on the client with the same information. Ensures correct
identification of the client.
 Do not agitate the tube. Agitation may cause RBC hemolysis.
 Send tube to the laboratory.
IMPLICATIONS OF ABNORMAL RESULTS:
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Apply pressure to the venipuncture site
 Explain that some bruising, discomfort, and swelling may appear at the site and that warm, moist
compresses can alleviate this.
 Monitor for signs of infection.
 Inform client of blood type when known.
J. RH FACTOR BLOOD TEST
DEFINITION:
 Rh testing measures the Rh factor, which is a system of blood typing that identifies protein on the surface
of the red blood cell. If a person’s blood has an Rh antigen, the blood is Rh positive. If there are no Rh
antigens, the blood is Rh negative. The Rh testing can also determine if the Rh-negative client has been
sensitized to Rh-positive antigen. The most common way for the mother to be sensitized to Rh-positive
antigens is during labor and delivery of her first Rh-positive child (Note: It is possible for her to be
sensitized after miscarriage, ectopic pregnancy, induced abortion, amniocentesis, or receiving a blood
transfusion with Rh antigens). If the pregnant mother is Rh-negative and is carrying an Rh-positive baby, it
is possible for the mother to make antibodies that would recognize the baby’s blood as foreign, which
would initiate an immune response
PURPOSE:
 To determine whether an individual is Rh positive or Rh negative
INDICATIONS:
 Rh testing is routinely done on pregnant women or women who wish to become pregnant and their
partners.
 Monitors Rh antibodies, which may be done in the Rh-sensitized pregnant mother.
 Evaluates potential for an Rh problem after a blood transfusion reaction
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Hemolyzed specimen invalidates results.
 Specimen drawn from extremity into which blood or dextran is infusing invalidates results. 3. Drugs
causing a false-positive Rh test include levodopa, methyldopa, and methyldopate hydrochloride.
 Abnormal plasma proteins, cold autoagglutinins, positive direct antiglobulin test, and in some cases,
bacteremia may interfere with results.
EQUIPMENTS:
 Lavender-top tube; needle and syringe or vacutainer
NORMAL VALUES:
 Rh-positive or Rh-negative. The results are informational regarding blood type.
 Note: if a pregnant mother is Rh-negative and the fetus she is carrying is Rh-positive, the fetus is at risk of
developing Rh disease.
PROCEDURE:
 Label the specimen tube. Correctly identifies the client and the test to be performed.
 Obtain a 5mL blood sample.
 Gently invert tubes several times, but do not agitate the tube. Mix the anticoagulant, but agitation may
cause RBC hemolysis.
 Send tube to the laboratory.
 If obtaining other tube of for blood testing, have a separate lavender-top tube solely for the Rh testing. This
may mean two or more lavender-top tubes. The Rh sample is sent to the blood bank and the other tubes
may be processed in a different laboratory. In addition, when drawing multiple samples, draw the
lavender-top tubes last. Prevents contamination of preservatives in the other tubes.
IMPLICATIONS OF ABNORMAL RESULTS:
 The significance of Rh antigens is based on their capacity to immunize the patient as a result of receiving a
transfusion or becoming pregnant.
 Antibodies for Rh2(C) are frequently found, together with antiRh1(D) antibodies, in the Rh-negative,
pregnant woman whose fetus or child is type Rh positive and possesses both antigens.
 With exceedingly rare exceptions, Rh antibodies do not form unless preceded by antigenic stimulation, as
occurs with pregnancy and abortions; blood transfusions; and deliberate immunization, most commonly of
repeated IV injections of blood for the purpose of harvesting a given Rh antibody.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Apply pressure to the venipuncture site
 Explain that some bruising, discomfort, and swelling may appear at the site and that warm, moist
compresses can alleviate this.
 Monitor for signs of infection.
 Counsel the client and her partner regarding the risk of Rh disease to the baby.
 Explain that RhoGAM, or RhIg, can be given by injection at 2 weeks’ gestation and again within 72 hours
after delivery.
K. 12 COAGULATION FACTORS TEST
DEFINITION:
 Coagulation factor tests are blood tests that check the function of one or more of your coagulation factors.
Coagulation factors are known by Roman numerals (I, II VIII, etc.) or by name (fibrinogen, prothrombin,
hemophilia A, etc.). If any of your factors are missing or defective, it can lead to heavy, uncontrolled
bleeding after an injury.
FUNCTION OF 12 CLOTTING FACTORS:

PURPOSE:
 A coagulation factor test is used to find out if you have a problem with any of your coagulation factors. If a
problem is found, you likely have a condition known as a bleeding disorder.
INDICATIONS:
 You may need this test if you have a family history of bleeding disorders. Most bleeding disorders are
inherited. That means it is passed down from one or both of your parents.
 You may also need this test if your health care provider thinks you have a bleeding disorder that is not
inherited. Although uncommon, other causes of bleeding disorders include:
 Liver disease
 Vitamin K deficiency
 Blood-thinning medicines
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 A type of blood clotting disorder called disseminated intravascular coagulation
 Hardening of the arteries due to plaque buildup
 A blood clot
 Major traumatic injury
 Crush injury
 Sepsis
EQUIPMENTS:
 You don't need any special preparations for a coagulation factor test.
NORMAL VALUES:
PROCEDURE:
 Coagulation tests are conducted the same way as most blood tests. You may need to discontinue taking
certain medications prior to the test. No other preparation is necessary.
 Your healthcare provider will sterilize a spot on the back of your hand or inside your elbow. They will
insert a needle into a vein. Most people feel a minor stick.
 Your healthcare provider will draw and collect your blood. Then they’ll more likely place a bandage on the
puncture site.
 The side effects of a coagulation test are generally minor. You may have slight soreness or bruises at the
site. The risks include lightheadedness, pain, and infection.
 If you have experience excessive bleeding, the procedure will be carefully monitored.
 The sample will be sent to a laboratory for testing and analysis.
IMPLICATIONS OF ABNORMAL RESULTS:
 If your results show one of your coagulation factors is missing or not working right, you probably have
some kind of bleeding disorder. The type of disorder depends on which factor is affected. While there is no
cure for inherited bleeding disorders, there are treatments available that can manage your condition.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Report abnormal signs and symptoms promptly.
 Use caution when providing care to minimize the risk of additional trauma to tissue.
 Recognize and support the emotional needs of patient and family.
L. BRAIN NATREURETIC PEPTIDE (BNP)
DEFINITION:
 Brain natriuretic peptide (BNP) is a peptide hormone that is released in response to volume expansion and
the increased wall stress of cardiac myocytes. BNP helps to promote diuresis, natriuresis, vasodilation of
the systemic and pulmonary vasculature, and reduction of circulating levels of endothelin and aldosterone.
PURPOSE:
 The test also shows if your heart failure has worsened. It’ll help your doctor decide what treatments you
need and if you need to be hospitalized.
INDICATIONS:
 Natriuretic peptides are used to identify and stratify patients with Congestive Heart Failure.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 The most prevalent side effect of nesiritide is hypotension, which can be long-lasting. Therefore, it is
important to monitor arterial pressure during drug administration. Azotemia (an elevated blood level of
urea or other nitrogen containing compounds) can occur in patients with renal disease in which kidney
function depends on the activated renin-angiotensin-aldosterone system. This drug should not be used in
patients having cardiogenic shock or having systolic pressures less than 90 mmHg. Side effects of the
sacubitril-valsartan combination include hypotension, hyperkalemia, angioedema, cough, and renal failure,
largely due to the valsartan. Furthermore, the presence of valsartan makes this combination unsuitable in
pregnancy.
INTERFERRING FACTORS:
 BNP levels are elevated in patients who have had cardiac surgery for 1 month postoperatively. This does
not reflect the presence of CHF.
 There are several different methods of measuring BNP. Normal values vary whether or not the whole
protein of a BNP fragment protein is measured.
 Natrecor (nesiritide), a recombinant form of the endogenous human peptide used to treat CHF, will
increase plasma BNP levels for several days.
EQUIPMENTS:
 Blood tube commonly used
 Lavender
PATIENT PREPARATION:
 There is no food, fluid, activity, or medication restrictions unless by medical direction.
NORMAL VALUES:
 BNP: < 100 pg/mL
 NT-pro-BNP: < 300 pg/mL
PROCEDURE:
 A blood sample is needed. The blood is taken from a vein (venipuncture). This test is most often done in
the emergency room or hospital. Results take up to 15 minutes. In some hospitals, a finger prick test with
rapid results is available.
IMPLICATIONS OF ABNORMAL RESULTS:
 Increased in:
 BNP is secreted in response to increased hemodynamic load caused by physiological stimuli, as with
ventricular stretch or endocrine stimuli from the aldosterone/renin system. Increasing BNP levels
would indicate a worsening condition.
Acute kidney injury
Cardiac inflammation (myocarditis, cardiac allograft rejection)
Chronic kidney disease
Cirrhosis
Cushing syndrome
Heart failure
Kawasaki disease
Left ventricular hypertrophy
Myocardial infarction
Primary hyperaldosteronism
Primary pulmonary hypertension
Ventricular dysfunction
 Decreased in:
 Decreasing BNP levels would indicate improvement.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 After the Study: Potential Nursing Actions
 Treatment Considerations
 CARDIAC OUTPUT: Assess peripheral pulses and capillary refill. Monitor blood pressure and check
for orthostatic changes (dizziness) related to fluid loss. Assess respiratory rate, breath sounds,
orthopnea, skin color and temperature, and level of consciousness. Monitor urinary output, sodium and
potassium levels, and BNP levels. Administer ordered oxygen and use pulse oximetry to monitor
oxygenation. Administer ordered medications aldosterone antagonists, angiotensin-converting enzyme
(ACE) inhibitors, beta blockers, diuretics, inotropic drugs, and vasodilators. Explain the importance of
taking prescribed medications to support cardiac health.
 EXCESS FLUID VOLUME: Daily weight with monitoring of trends. Limit fluid as appropriate.
Assess for peripheral edema, JVD, adventitious lung sounds such as crackles. Monitor blood pressure,
heart rate, and intake versus output. Administer prescribed diuretics, restrict sodium intake, and order a
low-sodium diet. Monitor laboratory values that reflect alterations in fluid status and manage
underlying cause of fluid alteration.
 GAS EXCHANGE: Auscultate and trend breath sounds. Assess respiratory rate and administer
ordered oxygen with pulse oximetry to monitor oxygenation. Collaborate with the health-care provider
(HCP) to consider intubation and/or mechanical ventilation as appropriate. Place the head of the bed in
high Fowler position. Administer ordered diuretics and vasodilators. Monitor potassium levels.
 TISSUE PERFUSION: Monitor blood pressure. Assess for dizziness, pedal pulses, capillary refill, and
skin temperature for warmth.
 Instruct patients to consume a variety of foods within the basic food groups, eat foods high in potassium
when taking diuretics, eat a diet high in fiber (25–35 g/day), maintain a healthy weight, be physically
active, limit salt intake to 2,000 mg/day, limit alcohol intake, and be a nonsmoker.
 Recommend consultation with a registered dietitian. High-potassium foods (bananas, strawberries,
oranges; cantaloupes; green leafy vegetables such as spinach and broccoli; dried fruits such as dates,
prunes, and raisins; legumes such as peas and pinto beans; nuts and whole grains) can offset the loss of
potassium from taking diuretics. Emphasize limiting dietary salt to recommended daily amount.
M. HEMOCYSTEINE
DEFINITION:
 Homocysteine is an intermediate amino acid formed during the metabolism of methionine. Increasing
evidence suggests that elevation in blood cells of homocysteine may be an independent risk for ischemic
heart disease, cerebrovascular disease and peripheral arterial disease. Homocysteine appears to promote
the progression of atherosclerosis by causing endothelial damage, promoting low-density (LDL) deposition
and promoting the growth of vascular smooth muscle.
PURPOSE:
 To help determine if you are deficient in vitamins B6, B9 (folate) or B12; to determine if you are at
increased risk of heart attack or stroke; to monitor those who have heart disease; sometimes to help
diagnose a rare inherited disorder called homocystinuria in newborns
INDICATIONS:
 When your healthcare provider suspects that you have a vitamin B6, B12 or folate deficiency; when you
have had a heart attack or stroke and do not have traditional risk factors, such as unhealthy lipid levels
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 The following conditions are contraindicated with this drug. Check with your physician if you have any of
the following:
 Conditions:
Low amount of potassium in the blood
Leber's hereditary optic atrophy
Inflammation of the stomach called atrophic gastritis
Past history of complete removal of stomach
 Allergies:
Cobalt
Cobalamin and Derivatives
Folic Acid Containing Drugs
Vitamin B
Vitamin B6 Preparations - Pyridoxine
EQUIPMENTS:
 For plasma test: Tube: lavender topped.
 Obtain a clean, random urine specimen container and ice for urine test.
 Client and Family Teaching: Fast from food and fluids for 8 hours before the test.
NORMAL VALUES:
SI UNITS
Plasma
From the Hordaland Homocysteine Study:
Norms in nonsmoking adults 40-42 years of age with high folate 3.0-4.8 μmol/L
intake and who drink less than 1 cup of coffee per day

Findings from Other Studies:


 Preterm infants up to 48 hours of age 3.5-4.1 μmol/L
 Term infants 4.8-7.4 μmol/L
 12-19 years of age
 Male 4.3-9.9 μmol/L
 Female 3.3-7.2 μmol/L
 20-59 years
 Male 6.5-11.43 μmol/L
 Female 5.35-9.95 μmol/L
 >59 years
 Male 5.9-15.3 μmol/L
 Female 5.3-15.3 μmol/L
 >100 years 4.9-37.3 μmol/L
Urine 0-9 μmol/g of Creatinine
PROCEDURE:
 For plasma test: Collect a 2-mL blood sample.
 For urine test: Collect random urine sample from second morning void. Place specimen immediately on
ice.
IMPLICATIONS OF ABNORMAL RESULTS:
 If your results show high homocysteine levels, it may mean:
 You are not getting enough vitamin B12, B6, or folic acid in your diet.
 You are at a higher risk of heart disease.
 Homocystinuria. If high levels of homocysteine are found, more testing will be needed to rule out or
confirm a diagnosis.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Send specimen to the lab immediately.
 Process specimen immediately (that is, within 30 minutes) to separate plasma. Specimen may be stored
refrigerated or frozen up to 48 hours.
N. ERYTHROCYTE SEDIMENTATION RATE (ESR)
DEFINITION:
 Measurement of the distance in millimeters that erythrocytes fall from the top of a vertical tube during
one hour for the evaluation and management of inflammatory states; serves as a marker of red cell
aggregation.
PURPOSE:
 Used to detect illnesses associated with acute and chronic infection advanced neoplasm, and tissue
necrosis or infarction.
INDICATIONS:
 Suspected and known Kawasaki disease - ESR is generally > 20 mm/hr in acute disease, subsiding to
normal 6 to 10 weeks after fever onset. An elevated ESR > 40 mm/hr in so-called incomplete Kawasaki
disease is a strong indication to proceed with further laboratory testing and an echocardiogram. A marked
elevation of 100 mm/hr or greater, or a persistent elevation, is consistent with active angitis and is
predictive of coronary artery involvement.
 Suspected bursitis - ESR is usually elevated, but the ESR does not distinguish between infection and other
causes of inflammation.
 Suspected giant cell (temporal) arteritis - marked elevation of ESR (e.g., > 50 mm/hr) is a hallmark
finding in this arteritis. A normal ESR level combined with low clinical suspicion reduces the probability
of disease to less than 1%. Normal ESR has been noted in up to 24% of biopsy-proven giant cell arteritis
patients before steroid therapy.
 Suspected gout - ESR often is mildly increased during gout attacks but may be as high as 2 times normal,
indicating inflammation.
 Suspected Lyme disease - ESR >30 mm/hr may be seen in 25% to 50% of patients. ESR in patients with
chronic arthritis ranges from 4 to 54 mm/hr (median, 24 mm/hr). In patients with cardiac involvement, the
ESR ranges from 3 to 74 mm/hr (median, 47 mm/hr) ESRs ranging from 2 to 46 mm/hr (median, 22
mm/hr)
INTERFERRING FACTORS:
 Artificially low results can occur when the collected specimen is allowed to stand longer than 3 hours
before the testing.
 Pregnancy (second and third trimesters) can cause elevated levels.
 Menstruation can cause elevated levels.
 Polycythemia is associated with decreased ESR.
 Drugs that may cause increased ESR levels include dextran, methyldopa, oral contraceptives,
penicillamine, procainamide, theophylline and vitamin A.
 Drugs that may cause decreased levels include aspirin, cortisone and quinine.
EQUIPMENTS/PATIENT PREPARATION:
 Sediplast ESR system
 Sediplast rack
 Disposable Pipette
 Timer
 Fasting or a special diet is not required.
NORMAL VALUES:
 Adult males: 0-17 mm/hour
 Adult females: 1-25 mm/hour
 Children: 0-10 mm/hour * (PDR)
 Westergreen method
 Male: up to 15 mm/hour
 Female: up to 20 mm/hour
 Child: up to 10 mm/hour
 Newborn: 0-2 mm/hour
PROCEDURE:
 Collect whole blood or capillary blood (suitable in pediatric patients).
 Transfer the specimen immediately to the laboratory.
 Apply pressure or a pressure dressing to the venipuncture site and assess the site for bleeding.
 In the laboratory, the blood is aspirated into a calibrated sedimentation tube and allowed to settle, usually
for 60 minutes. The remaining clear area (plasma) is measured as the sedimentation rate.
 An alternate method is performed by measuring the distance (in millimeters) that RBCs descent (or settle)
in normal saline solution in 1 hour. These processes are now automated.
IMPLICATIONS OF ABNORMAL RESULTS:
 If your ESR is high, it may be related to an inflammatory condition, such as:
 Infection
 Rheumatoid arthritis
 Rheumatic fever
 Vascular disease
 Inflammatory bowel disease
 Heart disease
 Kidney disease
 Certain cancers
 Sometimes the ESR can be slower than normal. A slow ESR may indicate a blood disorder, such as:
 Polycythemia
 Sickle cell anemia
 Leukocytosis, an abnormal increase in white blood cells
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Discomfort or bruising may occur at the puncture site. Pressure applied to the puncture site until the
bleeding stops reduces bruising. Warm packs to the puncture site relieve discomfort. The patient may feel
dizzy or faint.
O. ANTISTREPTOLYSIN O TITER
DEFINITION:
 Antibody to the streptolysin-O enzyme produced by Lancefield group A beta-hemolytic streptococci.
These titers rise about 7 days after infection, peak at 3-5 weeks, and then gradually return to baseline
level over the next 6-12 months. Because ASO titers remain elevated in clients with post-streptococcal
infections, the test is used to determine whether symptoms such as joint pains, rheumatic fever, or
glomerulonephritis are of a post-streptococcal disease origin.
PURPOSE:
 This test is done if you have symptoms of a previous infection by group A Streptococcus. Some illnesses
caused by these bacteria are:
 Bacterial endocarditis
 Glomerulonephritis, a kidney problem
 Rheumatic fever, which can affect the heart, joints, or bones
 Scarlet fever
 Strep throat
 The ASO antibody may be found in the blood weeks or months after the strep infection has gone
away.
INDICATIONS:
 This test is used to identify antecedent infection by group A streptococcal bacterium.
INTERFERRING FACTORS:
 An increased titer can occur in healthy carriers.
 Antibiotic therapy suppresses streptococcal antibody response.
 Increased B-lipoprotein levels inhibit streptolysin O and procedure falsely high ASO titers.
EQUIPMENTS:
 Latex particle coated with streptolycin O
 0.9% NaCl solution
 Glass slide with 6 cells
 Applicator sticks (stirrer)
 Control reagent
 Timer
 Test tubes
 Pasture pipettes and rubber bulb
 Serologic pipette and safety bulb
NORMAL VALUES:
 Adults
 <330 IU/mL
 Children
 <2 years: <200 IU/mL
 2-5 years: <240 IU/mL
 5-19: <330 IU/mL
PROCEDURE:
 Draw a 4-mL blood sample.
 Draw a repeat titer in 10-14 days.
IMPLICATIONS OF ABNORMAL RESULTS:
 Increased
 Acute post-streptococcal endocarditis, acute post-streptococcal glomerulonephritis (500-5000 Todd
U/mL), pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections
(PANDAS), reactive arthritis, rheumatic fever (inactive is <250 Todd U/mL; active is 500-5000
Todd U/mL), scarlet fever, recent streptococcal disease (small elevations), Sydenham’s chorea,
Tourette’s syndrome.
 Decreased
 Not clinically significant. Levels may decrease with antibiotic therapy.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Send the specimen to the laboratory for immediate spinning.
 Client and Family Teaching
 Repeated ASO titers every 10-14 days are recommended. When post-streptococcal disease occurs,
titers begin to rise 1 week after the initial streptococcal infection and peak 2-4 weeks later; 6 months
to 1 year is required for post-infection levels to return to the baseline level.
 Results may not be available for several days if testing is not performed on site.
P. TOURNIQUET TEST
DEFINITION:
 A test used to determine pain thresholds or, alternately, capillary fragility. A blood pressure cuff is
inflated sufficiently to occlude venous return. It is kept in place for a set time. The anesthetic effect, or
the impact on skin integrity, is subsequently assessed.
PURPOSE:
 To assess the quality of the evidence supporting the use of the TT and perform a diagnostic accuracy
meta-analysis comparing the TT to antibody response measured by ELISA.
INDICATIONS:
 Elective lower limb surgery of the knee and lower leg
 Elective upper limb surgery of the elbow, forearm and hand
 Emergency or urgent surgery of closed injuries to the same and open injuries of the hand.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Contraindications:
 Open injuries of the limb
 Wounds that require debridement and irrigation
 Reamed intramedullary nailing
 Peripheral vascular disease
 Diabetic foot disease
 Interfering factors:
 Women who are premenstrual
 Postmenstrual and not taking hormones
 Damaged skin all will have increased capillary fragility.
EQUIPMENTS:
 Blood pressure cuff
 Stethoscope
 Drape
 Measuring tape
 Pressure display testing equipment
 Elastic bandage
NORMAL VALUES:
 No pain with prolonged testing
PROCEDURE:
 Measure the blood pressure
 Pump up a blood pressure cuff on one of the arm to the pressure halfway between the diastolic and
systolic blood pressure
 Keep it for 5 minutes and then ease the pressure
 Examine the extremity of the pressure of petechiae
 The number of petechiae within a circumscribed area of the skin may be counted, or the results may be
reported in a range from negative (no petechiae) to +4 positive (confluent petechiae).
 The tourniquet test can be negative especially early in the disease or in obese patients or in patients with
shock
IMPLICATIONS OF ABNORMAL RESULTS:
 If atherosclerosis is absent, an increase in pain with prolonged testing usually indicates the presence of
deep venous obstruction or thrombosis
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Keep the client at bed rest and ensure safety to prevent from injury
 Client is usually placed in dorsal recumbent position.
 Hourly monitoring noting for narrowing pulse pressure, sudden drop in temperature, decreased blood
pressure and pulse rate and other signs of deterioration.
II. DIAGNOSTIC PROCEDURES
A. ELECTROCARDIOGRAPHY OR ELECTROPCARDIOGRAM
DEFINITION:
 An electrocardiogram (ECG or EKG) is a test that checks how your heart is functioning by measuring the
electrical activity of the heart. With each heartbeat, an electrical impulse (or wave) travels through your heart.
This wave causes the muscle to squeeze and pump blood from the heart.
.1. LEAD 1-4 MEASUREMENT:
 Lead I: RA (-) to LA (+) (Right Left, or lateral)
 Lead II: RA (-) to LL (+) (Superior Inferior)
 Lead III: LA (-) to LL (+) (Superior Inferior)
.2. VR-VF MEASUREMENT:
 Lead aVR: RA (+) to [LA & LL] (-) (Rightward)
 Lead aVL: LA (+) to [RA & LL] (-) (Leftward)
 Lead aVF: LL (+) to [RA & LA] (-) (Inferior)
.3. V1-V6
 Leads V1, V2, V3: (Posterior Anterior)
 Leads V4, V5, V6: (Right Left, or lateral)
INDICATIONS:
 An ECG may be recommended if you are experiencing arrhythmia, chest pain, or palpitations and an abnormal
ECG result can be a signal of a number of different heart conditions.
SIGNIFICANCE OF THE ECG RHYTHM:
 DECREASED R WAVE
 Poor R-wave progression (PRWP) is a common ECG finding that is often inconclusively interpreted as
suggestive, but not diagnostic, of anterior myocardial infarction (AMI)
 ELONGATION OF T WAVE
 The T wave is the most labile wave in the ECG. T wave changes including low-amplitude T waves and
abnormally inverted T waves may be the result of many cardiac and non-cardiac conditions .
 DEPRESSION OF ST SEGMENT
 Is often a sign of myocardial ischemia, of which coronary insufficiency is a major cause.
 HYPERKALEMIA
 Kidneys normally excrete potassium so disorders that decrease the function of the kidneys can result in
hyperkalemia.
 HYPOKALEMIA
 Muscular malfunction may result in paralysis of the bowel, low blood pressure, muscle twitches and
mineral deficiencies (tetany). Severe hypokalemia may also lead to disruption of skeletal muscle cells,
particularly during exercise.
 HYPOCALCEMIA
 May lead to cardiac dysrhythmias, decreased cardiac contractility causing hypotension, heart failure or
both.
 HYPERCALCEMIA
 Constipation, anorexia, nausea and vomiting, abdominal pain and ileus.
 HYPOMAGNESEMIA
 Ventricular arrhythmia, coronary artery vasospasm, sudden death
 HYPERMAGNESEMIA
 Lethargy, drowsiness, hypotension, nausea, vomiting, facial flushing, urinary retention, and ileus
COMPONENTS OF ECG RHYTHM
 P WAVE
 A record of the electrical activity through the upper heart chambers (atria).
 PR INTERVAL
 The time from the onset of the P wave to the start of the QRS complex. It reflects conduction through
the AV node.
 QRS COMPLEX
 A record of the movement of electrical impulses through the lower heart chambers (ventricles).
 T WAVE
 Shows when the lower heart chambers are resetting electrically and preparing for their next muscle
contraction.
 ST SEGMENT
Shows when the ventricle is contracting but no electricity is flowing through it. The st segment usually
appears as a straight, level line between the QRS complex and the t wave.
 QT SEGMENT
 The time from the start of the Q wave to the end of the T wave. It represents the time taken for
ventricular depolarization and repolarization, effectively the period of ventricular systole from
ventricular isovolumetric contraction to isovolumetric relaxation
 U WAVE
 Probably represents the final state of repolarization of the ventricles.
PREPARATION BEFORE THE PROCEDURE:
 Avoid oily or greasy skin creams and lotions the day of the test because they can keep the electrodes from
making contact with your skin.
 Avoid full-length hosiery, because electrodes need to be placed directly on your legs.
 Wear a shirt that you can remove easily to place the leads on your chest.
PRECAUTIONS:
 The electrode should be changed periodically before the adhesive performance decreases
 Change the battery of the transmitter immediately when the central monitor shows the battery change
indicator, regardless of whether there is an alarm or not.
 Check and see what area of the hospital rooms the monitor antenna covers.
PROCEDURE:
 When you go for an ECG test, you will need to remove your upper clothing so that electrodes can be
attached to your chest and limbs. (For women, wearing a separate top with trousers or a skirt can allow
easy access to the chest.) The selected sites are shaved, if necessary.
 Electrodes (sensors) are attached to the chest, arms and legs with suction cups or sticky gel. These
electrodes detect the electrical currents generated by the heart – these are measured and recorded by the
electrocardiograph.
 The three major types of ECG are:
 RESTING ECG – you lie down for this type of ECG. No movement is allowed during the test, as
electrical impulses generated by other muscles may interfere with those generated by your heart. This
type of ECG usually takes 5 to 10 minutes
 AMBULATORY ECG – if you have an ambulatory or Holter ECG you wear a portable recording
device for at least 24 hours. You are free to move around normally while the monitor is attached. This
type of ECG is used for people whose symptoms are intermittent (stop-start) and may not show up on
a resting ECG, and for people recovering from heart attack to ensure that their heart is functioning
properly. You record your symptoms in a diary, and note when they occur so that your own experience
can be compared with the ECG
 CARDIAC STRESS TEST – this test is used to record your ECG while you ride on an exercise bike
or walk on a treadmill. This type of ECG takes about 15 to 30 minutes to complete.
NORMAL TIME DURATION FOR WAVES & INTERVAL:
 P WAVE – 0.06 – 0.11 seconds
 PR INTERVAL – 0.12 – 0.20 seconds
 QRS – 0.08 – 0.12 seconds
 QT INTERVAL (MEN & WOMEN) – 0.35 – 0.43 seconds
NURSING RESPONSIBILITES:
 BEFORE THE PROCEDURE
 Explain the procedure to the patient. Inform the patient that echocardiography is used to evaluate the
size, shape, and motion of various cardiac structures. Tell who will perform the test, where it will take
place, and that it’s safe, painless, and is noninvasive.
 No special preparation is needed. Advise the patient that he doesn’t need to restrict food and fluids for
the test.
 Ensure to empty the bladder. Instruct patient to void prior and to change into a gown.
 Encourage the patient to cooperate. Advise the patient to remain still during the test because
movement may distort results. He may also be asked to breathe in or out or to briefly hold his breath
during the exam.
 Explain the need to darkened the examination field. The room may be darkened slightly to aid
visualization on the monitor screen, and that other procedure (ECG and phonocardiography) may be
performed simultaneously to time events in the cardiac cycles.
 Explain that a vasodilator (amyl nitrate) may be given. The patient may be asked to inhale a gas with a
slightly sweet odor while changes in heart functions are recorded.
 DURING THE PROCEDURE
Inform that a conductive gel is applied to the chest area. A conductive gel will be applied to his chest
and that a quarter-sized transducer will be placed over it. Warn him that he may feel minor discomfort
because pressure is exerted to keep the transducer in contact with the skin.
 Position the patient on his left side. Explain that transducer is angled to observe different areas of the
heart and that he may be repositioned on his left side during the procedure.
 AFTER THE PROCEDURE
 Remove the conductive gel from the patient’s skin. When the procedure is completed, remove the gel
from the patient’s chest wall.
 Inform the patient that the study will be interpreted by the physician. An official report will be sent to
the requesting physician, who will discuss the findings with the patient.
 Instruct patient to resume regular diet and activities. There is no special type of care given following
the test.
ILLUSTRATE:
 Sample tracing of PQRS complex, sinus tachycardia, ventricular fibrillation, Mitral stenosis, acute MI,
sinus bradycardia, normal sinus rhythm, Premature ventricular contraction.
 PQRS COMPLEX

 SINUS TACHYCARDIA

 VENTRICULAR FIBRILATION

 MITRAL STENOSIS
 ACUTE MI

 SINUS BRADYCARDIA

 NORMAL SINUS RHYTHM

 PREMATURE VENTRICULAR CONTRACTION

 Draw the heart and indicate V1-V6 locations


 Draw the body and indicate L1-L4 located

B. ECHOCARDIOGRAPHY
DEFINITION:
 The primary diagnostic test for heart disease. High-frequency sound waves, directed toward the heart, are used
to locate and study the movement and dimensions of cardiac structures, such as the size of chambers, thickness
of walls, relationship of major vessels to chambers, and the thickness, motion, and pressure gradients of valves.
This technique is referred to as m-mode, a single beam that reveals chamber contractility; two-dimensional, a
technique used to reveal chamber and vessel size; and doppler technique, which reveals the velocity of blood
flow.
PURPOSE:
 This test allows your doctor to monitor how your heart and its valves are functioning. The images can help
them get information about: blood clots in the heart chamber; fluid in the sac around the heart; problems with
the aorta, which is the main artery connected to the heart; problems with the pumping function or relaxing
function of the heart; problems with the function of your heart valves; and pressures in the heart. An
echocardiogram is key in determining the health of the heart muscle, especially after a heart attack. It can also
reveal heart defects in unborn babies.
INDICATIONS:
 Coronary artery disease diagnosis
 To assess adequacy before and after revascularization
 Risk stratification in known coronary diseases
 Identifying the location of ischemia
 Preoperative risk assessment
 Evaluation for cardiac etiology of exertional dyspnea
 To assess valve disease
 Left bundle branch block
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Esophageal obstructions, stenosis, fistula, dysphagia or varices (> grade 2); history of radiation therapy to the
esophagus or surrounding area (mediastinum); acute penetrating chest injuries.
 Neonates and young children are not candidates because of the unavailability of specially sized TEE scopes.
 Sedatives are contraindicated in clients with central nervous system depression. Also contraindicated in clients
who cannot tolerate lying flat.
EQUIPMENTS:
 The equipment required for echocardiography includes an echocardiography machine, a suitable transducer,
and, for contrast examinations, contrast material. Proper adjustment of the settings on the echocardiography
machine is crucial.
PATIENT PREPARATION:
 Your doctor will explain the procedure to you and ask if you have any questions.
 Generally, you don't need to do any preparation such as fasting or having sedation.
 Tell your doctor of all prescription and over-the-counter medicines and herbal supplements that you are taking.
 Tell your doctor if you have a pacemaker.
 Based on your medical condition, your doctor may request other specific preparation.
NORMAL VALUES:
 For mitral valve: Anterior and posterior mitral valve leaflets separating in early diastole and attaining
maximum excursion rapidly, then moving toward each other during ventricular diastole; after atrial
contraction, mitral valve leaflets coming together and remaining together during ventricular systole.
 For aortic valve: Aortic valve cusps moving anteriorly during systole and posteriorly during diastole.
 For tricuspid valve: The motion of the valve resembling that of the mitral valve.
 For pulmonic valve: Movement occurring posterior during atrial systole and ventricular ejection, cusp
moving anteriorly, attaining its most anterior position during diastole.
 For ventricular cavities: Left ventricular cavity normally an echo-free space between the interventricular
septum and the posterior left ventricular wall.
 Right ventricular cavity: Normally an echo-free space between the anterior chest wall and the
interventricular septum.
PROCEDURE:
 You will remove any jewelry or other objects that may interfere with the procedure. You may wear your
glasses, dentures, or hearing aids if you use any of these.
 You will remove clothing from the waist up and will be given a gown to wear.
 You will lie on a table or bed, on your left side. A pillow or wedge may be placed behind your back for
support.
 You will be connected to an ECG monitor that records the electrical activity of the heart and monitors the heart
during the procedure using small, adhesive electrodes. The ECG tracings that record the electrical activity of
the heart will be compared with the images displayed on the echocardiogram monitor.
 The room will be darkened so that the images on the echo monitor can be seen by the technologist.
 The technologist will place warmed gel on your chest and then place the transducer probe on the gel. You will
feel a slight pressure as the technologist positions the transducer to get the desired images of your heart.
 During the test, the technologist will move the transducer probe around and apply varying amounts of pressure
to get images of different locations and structures of your heart. The amount of pressure behind the probe
should not be uncomfortable. If it does make you uncomfortable, let the technologist know. You may be asked
to hold your breath, take deep breaths, or even sniff through your nose during the procedure.
 If the structures of your heart are hard to see, the technologist may use an IV contrast that helps the heart
chambers show up better. This is not an iodine based contrast so you don't have to worry if you have an allergy
to shrimp or shellfish with this type of contrast.
 After the procedure, the technologist will wipe the gel from your chest and remove the ECG electrode pads.
You may then put on your clothes.
IMPLICATIONS OF ABNORMAL RESULTS:
 Abnormal echocardiogram findings will show the following:
 In mitral stenosis: Valve narrowing abnormally because of the leaflets’ thickening and disordered
motion; during diastole, both mitral valve leaflets moving anteriorly instead of posteriorly.
 In mitral valve prolapse: One or both leaflets ballooning into the left atrium during systole.
 In aortic insufficiency: Aortic valve leaflet fluttering during diastole.
 In stenosis: Aortic valve thickening and generating more echoes.
 In bacterial endocarditis: Disrupted valve motion and fuzzy echoes usually on or near the valve.
 Large chamber size: May indicate cardiomyopathy, valvular disorders, or heart failure: small chamber
size: may indicate restrictive pericarditis.
 Hypertrophic cardiomyopathy: Identified by a systolic anterior motion of the mitral valve and
asymmetrical septal hypertrophy.
 Myocardial ischemia or infarction: May cause absent or paradoxical motion in ventricular walls.
 Pericardial effusion: Fluid accumulates in the pericardial space, causing an abnormal echo-free space.
 In large effusions: Pressure exerted by excess fluid restricting pericardial motion.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 DURING THE PROCEDURE
 Inform that a conductive gel is applied to the chest area. A conductive gel will be applied to his chest
and that a quarter-sized transducer will be placed over it. Warn him that he may feel minor discomfort
because pressure is exerted to keep the transducer in contact with the skin.
 Position the patient on his left side. Explain that transducer is angled to observe different areas of the
heart and that he may be repositioned on his left side during the procedure.
 AFTER THE PROCEDURE
 Remove the conductive gel from the patient’s skin. When the procedure is completed, remove the gel from
the patient’s chest wall.
 Inform the patient that the study will be interpreted by the physician. An official report will be sent to the
requesting physician, who will discuss the findings with the patient.
 Instruct patient to resume regular diet and activities. There is no special type of care given following the
test.
C. CHEST X-RAY
DEFINITION:
 The most commonly performed diagnostic x-ray examination. A chest x-ray produces images of the heart,
lungs, airways, blood vessels and the bones of the spine and chest. X-rays are passed through the chest and
react on a special photographic plate. Normally the lungs are radiolucent. Bones and fluid-containing bodies
such as the heart, the aorta, and any tumor or infiltrate are denser than the lungs and can be easily visualized.
PURPOSE:
 Chest radiography may be used as a general screening tool preoperatively or for general physical examinations
or may be prescribed for a specific diagnostic purpose.
 Provides information regarding the anatomic location and abnormalities of the heart, great vessels, lungs, soft
tissue of the chest and mediastinum, and the bones.
INDICATIONS:
 Known or suspected pulmonary infectious disorders disorders such as pneumonia, tuberculosis, or lung abscess
 Diagnosis of obstructive pulmonary lung diseases such as atelectasis, emphysema, or chronic bronchitis
 Diagnosis of interstitial lung diseases such as sarcoidosis, silicosis, or asbestosis
 Diagnosis of pneumothorax or fractures of the ribs or clavicles resulting from known or suspected chest trauma
 Known or suspected cardiovascular disorders such as congestive heart failure (CHF), pericarditis, or aortic
aneurysm
 Monitoring of pulmonary or cardiac disease to evaluate the effectiveness of therapy
 Suspected diaphragmatic hernia
 Suspected neoplasm (benign or malignant) involving the mediastinum, lungs, or chest wall
 Suspected pleural effusion or other abnormalities involving the pleurae or fluid accumulation in the lungs, as in
pulmonary edema
 Diagnosis of cystic fibrosis in children
 Diagnosis of bronchopulmonary dysplasia, air leak syndrome, hyaline membrane disease, and meconium
aspiration syndrome in infants
 Evaluation of the placement and positioning of endotracheal tubes, tracheostomy tubes, central
 venous catheters, Swan-Ganz catheters, chest tubes, NG feeding tubes, pacemaker wires, and intra-aortic
balloon pumps
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Screen the client for contraindications to performing the Valsalva maneuver (recent myocardial infarction,
bradycardia). If these conditions are present, teach the client how to hold breath without bearing down.
 During pregnancy, risks of cumulative radiation exposure to the fetus from this and other previous or future
imaging studies must be weighed against the benefits of the procedure.
 Although formal limits for client exposure are relative to this risk: benefit comparison, the United States
Nuclear Regulatory Commission requires that the cumulative dose equivalent to an embryo/ fetus from
occupational exposure not exceed 0.5 rem (5 mSv). Radiation dosage to the fetus is proportional to the distance
of the anatomy studied from the abdomen and decreases as pregnancy progresses.
 For pregnant clients, consult the radiologist/ radiology department to obtain estimated fetal radiation exposure
from this procedure.
EQUIPMENTS:
 Explain the procedure to the patient.
 Tell the patient the no fasting is required.
 Inform the patient that the examination is safe and painless
 Instruct the patient to remove clothing to the waist and to put on an x-ray gown
 Remove all metal objects so they do not block visualization of the part of the chest
 Tell the patient that he or she will be asked to take a deep breath and hold it while the x-ray films are obtained
 Inform the patient that no discomfort is associated with chest radiography
NORMAL VALUES:
 No anatomic or functional abnormalities exist. The organs are normal in size, shape, contour and position. The
internal structures of the organs and nearby tissues are within normal limits.
PROCEDURE:
 The client is positioned sitting or standing upright in front of the x-ray machine, with arms held slightly out
from the sides, chest expanded, and shoulders pressed forward. The radiographic film is placed against the
anterior chest.
 For lateral views, the client stands with his or her arms elevated from the shoulders and with the forearms
resting on the arm of the radiographic equipment, if necessary. The radiographic film is placed flush against
the right or left side of the chest.
 As the client holds very still and takes in a deep breath and holds it, one or more radiographs are taken.
 For portable radiographs, the client is positioned sitting in a high-Fowler’s position, and the portable x-ray
machine is moved into place in front of the chest for the radiographic exposure onto the plate positioned
behind the back and chest.
IMPLICATIONS OF ABNORMAL RESULTS:
 Abnormal in: lung tumors (primary or metastatic), pneumonia, pulmonary edema, pleural effusion,
pneumothorax, atelectasis, COPD, TB, lung abscess, congenital lung diseases, pleuritis, foreign body in the
chest, bronchus, or esophagus, cardiac enlargement, pericarditis, pericardial effusion, soft-tissue sarcoma,
osteogenic sarcoma, fracture of ribs or thoracic spine, thoracic scoliosis, metastatic tumor to bony thorax,
diaphragmatic or hiatal hernia, aortic calcinosis, enlarged lymph nodes, dilated aorta, thymoma, lymphoma,
substernal thyroid, widened sternum
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 DURING TEST
 After the patient is correctly positioned, tell him or her to take a deep breath and hold it until the x-ray
films are obtained
 POSTTEST:
 Inform the patient that the results will be available after a few minutes
D. CARDIAC STRESS TEST
DEFINITION:
 A stress test, shows how your heart works during physical activity. Because exercise makes your heart pump
harder and faster, a stress test can reveal problems with blood flow within your heart.
 Your doctor may recommend this if patient have signs or symptoms of coronary artery disease or an irregular
heart rhythm (arrhythmia). The test may also guide treatment decisions, measure the effectiveness of treatment
or determine the severity if patient have already been diagnosed with a heart condition.
 TYPES OF STRESS TEST:
 Cardiopulmonary exercise test (CPET)
This comprehensive test evaluates how well your heart and lungs work together to deliver oxygen-rich
blood to your body. It also shows how well your muscles use oxygen as you exercise at increasing
levels.
 Exercise stress test
This test uses an EKG during exercise to evaluate blood flow to your heart. We perform an exercise
stress test while you are exercising on a treadmill or stationary bicycle at a gradually increasing rate.
We use this test to raise your heart rate so that we can detect heart problems affecting blood flow.
 Pharmacologic stress test
This stress test evaluates blood flow to your heart using an EKG but does not involve any physical
activity. We recommend a pharmacologic stress test for people who are unable to exercise because of
physical limitations such as arthritis, joint or back conditions, injury, or disability. In this test, you
receive medication to stimulate your heart and cause it to beat harder and faster, as if you were
exercising.
 Nuclear stress test
This type of stress test includes radioactive dye and imaging studies to show blood flow to the heart,
both at rest and when your heart rate is elevated. As with other types of stress tests, we record your
heart’s electrical activity with an EKG.
PURPOSE:
 Cardiopulmonary exercise test (CPET)
 A CPET can assess:
Reasons for shortness of breath
Level of fitness and ability to exercise, especially after a heart attack or heart surgery
Lung function
 We use this test not only to identify many types of heart and lung conditions, but also to:
Monitor people who already have these conditions and check disease progression
Measure how well treatments are working
Determine whether exercise limitations are due to a heart or a lung problem
 Exercise stress test
 An exercise stress test measures only the electrical activity of your heart, not lung function like a CPET.
We use this test to:
Determine safe exercise levels after a heart attack or heart surgery
Diagnose and determine the severity of CAD and other types of heart disease
Diagnose an arrhythmia
Find the cause of symptoms that appear only during exercise, such as shortness of breath, fainting, or
irregular heartbeat
Guide treatment planning, such as medication, cardiac catheterization (minimally invasive heart
procedures), surgery, or transplantation
 Pharmacologic stress test
 We use a pharmacologic stress test to:
Determine safe levels of physical activity if you have had a heart attack or heart surgery
Diagnose many types of heart disease and determine their severity
Guide decisions on treatment options, such as medication, cardiac catheterization (minimally invasive
heart procedures), surgery, or transplantation
Assess how well your treatment is working to increase blood flow to the heart
 Nuclear stress test
 The scans provide details that can indicate heart disease and its severity and show tissue damage from a
previous heart attack.
INDICATIONS:
 Indicated for diagnosis and prognosis of cardiovascular disease, specifically CAD. This is the initial procedure
of choice in patients with a normal or near-normal resting electrocardiogram who are capable of adequate
exercise.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Absolute contraindications to cardiac stress testing include acute myocardial infarction (including the presence
of new left bundle branch block [LBBB]), high risk unstable angina, symptomatic severe aortic stenosis,
uncontrolled arrhythmia causing symptoms or hemodynamic instability, unstable heart failure, acute
pulmonary embolus and acute aortic dissection.
 Relative contraindications include left main coronary stenosis, severe arterial hypertension, electrolyte
abnormalities, hypertrophic obstructive cardiomyopathy and uncontrolled arrhythmia. 3 In the presence of a
relative contraindication the test may still proceed if the benefit of identifying ischemia outweighs the risk of
performing the test.
 It is important to ensure that the appropriate stress modality is ordered: if patients cannot walk at a reasonable
workload, order an imaging pharmacological stress test (e.g. dobutamine stress echocardiogram or persantin
nuclear stress test), noting that a stress ECG cannot be done on its own using pharmacological stress.
EQUIPMENTS:

 The doctor or a nurse will explain the procedure and offer the opportunity for patients to ask questions about
the procedure. Patients will then be asked to sign a consent form that gives permission to perform the test.
Read the form carefully and ask questions if something is not clear.
 Patients should notify the doctor about all medications (prescription and over-the-counter) and herbal
supplements that they are taking.
 During the test, we monitor the electrical activity of the heart and we ask patients to breathe through a face
mask. This allows us to monitor oxygen uptake. At the beginning and end of the test, we do an ultrasound
(echocardiogram) to look at the heart.
 If patients are physically unable to walk/jog on a treadmill, please alert the staff to allow for an alternative (e.g.
switch to a cardiac stress test using a drug). Once on the treadmill, the speed and incline will be gradually
increased until symptoms or fatigue, pain, or cardiac abnormality occurs.
 You will be asked to fast for a few hours before the procedure. You should not smoke for two hours prior to
the procedure. Do not have any caffeine or caffeine products for 24 hours
 If you are pregnant or suspect that you may be pregnant, you should notify your doctor
 Notify your doctor of all medications (prescription and over-the-counter) and herbal supplements that you are
taking
NORMAL VALUES:
 A normal test result means no blood flow problems were found.
PROCEDURE:
 EXERCISE STRESS TEST:
 A health care provider will place several electrodes (small sensors that stick to the skin) on your arms,
legs, and chest. The provider may need to shave excess hair before placing the electrodes.
 The electrodes are attached by wires to an electrocardiogram (EKG) machine, which records your heart's
electrical activity.
 You will then walk on a treadmill or ride a stationary bicycle, starting slowly.
 Then, you'll walk or pedal faster, with the incline and resistance increasing as you go.
 You'll continue walking or riding until you reach a target heart rate set by your provider. You may need to
stop sooner if you develop symptoms such as chest pain, shortness of breath, dizziness, or fatigue. The test
may also be stopped if the EKG shows a problem with your heart.
 After the test, you'll be monitored for 10–15 minutes or until your heart rate returns to normal.
 Both nuclear stress tests and stress echocardiograms are imaging tests. That means that pictures will be
taken of your heart during testing.
 NUCLEAR STRESS TEST:
 You will lie down on an exam table.
 A health care provider will insert an intravenous (IV) line into your arm. The IV contains a radioactive
dye. The dye makes it possible for the health care provider to view images of your heart. It takes between
15–40 minutes for the heart to absorb the dye.
 A special camera will scan your heart to create the images, which show your heart at rest.
 The rest of the test is just like an exercise stress test. You'll be hooked up to an EKG machine, then walk
on a treadmill or ride a stationary bicycle.
 If you are not healthy enough to exercise, you'll get a medicine that makes your heart beat faster and
harder.
 When your heart is working at its hardest, you'll get another injection of the radioactive dye.
 You'll wait for about 15-40 minutes for your heart to absorb the dye.
 You'll resume exercising and the special camera will take more pictures of your heart.
 Your provider will compare the two sets of images: one of your heart at rest; the other while hard at work.
 After the test, you'll be monitored for 10-15 minutes or until your heart rate returns to normal.
 The radioactive dye will naturally leave your body through your urine. Drinking lots of water will help
remove it faster.
IMPLICATIONS OF ABNORMAL RESULTS:
 If test result was not normal, it can mean there is reduced blood flow to the heart. Reasons for reduced blood
flow include:
 Coronary artery disease
 Scarring from a previous heart attack
 Your current heart treatment is not working well
 Poor physical fitness
 If exercise stress test results were not normal, the health care provider may order a nuclear stress test or a stress
echocardiogram. These tests are more accurate than exercise stress tests, but also more expensive. If these
imaging tests show a problem with your heart, the provider may recommend more tests and/or treatment.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Assist patient during the procedures to make sure he/she is doing it properly.
 After the test, patients are monitored for 10 to 15 minutes. Once stable, they may resume their usual activities.
 Patients are informed about the transient sensations they may experience during infusion of the vasodilating
agent, such as flushing or nausea, which will disappear quickly.
 The patient is instructed to report any other symptoms occurring during the test to the cardiologist or nurse.
E. IMPEDANCE CARDIOGRAPHY
DEFINITION:
 Impedance cardiography (ICG), also known as thoracic electrical bioimpedance (TEB), is a technology that
converts changes in thoracic impedance to changes in volume over time. In this manner, it is used to track
volumetric changes such as those occurring during the cardiac cycle. These measurements, which are gathered
noninvasively and continuously, have become more sophisticated and more accurate with the development of
data signal processing and improved mathematical algorithms.
PURPOSE:
 Used to measure hemodynamic parameters and metrics of cardiac function.
INDICATIONS:
 Heart valve disorders
 Abnormalities of the septum
 Wall motion abnormalities
 Diseases of the pericardium
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 For pregnant clients, consult the radiologist/ radiology department to obtain estimated fetal radiation exposure
from this procedure.
PATIENT PREPARATION:
 Tell patient to bring a small number of personal items to the hospital, such as pajamas, robe, slippers, and toilet
articles, including cases for glasses, contact lenses and dentures.
 Tell patient not to wear watches, jewelry, and other metallic objects during the procedure.
 For the safety of our pediatric patients under the age of 7, an adult is required to stay with them at all times. If
the child is under 2 years of age, the use of a baby bed is recommended for the safety of your child.
 Ask patient about the medications and supplements he takes.
 Ask patient if he/she have allergies.
NORMAL VALUES:
 In a progressive increase in age, body mass index, total cholesterol, low‐density lipoprotein‐cholesterol, fasting
glucose, and prevalence of diabetes mellitus and impaired fasting glucose, from non-hypertension to stage 2
hypertension, with a progressive decrease in estimated glomerular filtration rate. Serum triglycerides were
lower in non-hypertensive subjects compared with either stage 1 or 2 hypertension.
PROCEDURE:
IMPLICATIONS OF ABNORMAL RESULTS:
 Parameters measured by impedance cardiography (total arterial compliance index and indices of cardiac
contractility) predict mortality in the general population, even after adjustment for multiple confounders and
blood pressure.
 Subjects without stage 2 hypertension who demonstrate abnormal impedance cardiography indices of cardiac
contractility represent a large subpopulation could benefit from more‐aggressive or earlier interventions, which
should be addressed in future studies.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
F. CT SCAN
DEFINITION:
 Computed tomography (CT), also known as computed axial tomography or computed transaxial tomography,
is a noninvasive procedure that uses tomographic radiography (x-ray) combined with a special scanning
machine, detectors that determine the amount of radiographic beams absorbed by tissues, and a computer that
processes these readings and reconstructs a body region by calculating the differences in tissue absorption of
the radiographic beams.
PURPOSE:
 It produces a series of three-dimensional, cross-sectional anatomic views of the tissue structure of solid organs
as well as differences between soft tissue and water. Imaging can also reproduce sagittal, horizontal, and
coronal planes of tissue for viewing.
INDICATIONS:
 Identify presence, and extent of calcium buildup in the coronary arteries
 Evaluates the risk of atherosclerosis and coronary heart disease
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Pregnant patient (absolute contraindication)
 Patients with a known allergy to iodine
 Patients with claustrophobia
 Patients with renal impairment unless the benefits outweigh the risks
 Patients with hyperthyroidism or toxic goiter (induce thyrotoxic crisis)
 Patients with complications after a previous administration of a contrast
 Patients with severe obesity (usually more than 300 pounds)
 Inform about the duration of the procedure. Inform the patient that the procedure takes from five (5)
minutes to one (1) hour depending on the type of CT scan and his ability to relax and remain still.
EQUIPMENTS:
 Take off some or all of the clothing and wear a hospital gown.
 Remove any metal objects, such as a belt or jewelry, which might interfere with image results.
 Stop eating for a few hours before the scan.
 If a patient is going to have a contrast injection, he or she should not have anything to eat or drink for a few
hours before the CT scan because the injection may cause stomach upset.
 To receive the contrast injection, an IV is inserted into the arm just prior to the scan. The contrast then enters
the body through the IV.
 Prior to most CT scans of the abdomen and pelvis, it is important to drink an oral contrast agent that contains
dilute barium. This contrast agent helps the radiologist identify the gastrointestinal tract (stomach, small and
large bowel), detect abnormalities of these organs, and to separate these structures from other structures
within the abdomen.
 If the patient has a history of allergy to contrast material (such as iodine), the requesting physician and
radiology staff should be notified.
 The patient will be asked to drink slightly less than a quart spread out over 1.5 to 2 hours.
 If an infant or toddler is having the CT scan, the doctor may recommend a sedative to keep the child calm and
still. Movement blurs the images and may lead to inaccurate results.
NORMAL VALUES:
 Normal size and contour of body structures and organs; no pathology such as masses or abnormal
accumulation of body fluids or substances.
PROCEDURE:
 The patient is positioned on an adjustable table inside an encircling body scanner (gantry); straps and pillows
may be used to help in maintaining the correct position.
 The patient may be instructed to hold his breath during the scanning.
 A series of transverse radiographs are taken and recorded
 The information is reconstructed by a computer and selected images are photographed.
 Once the images are reviewed, an I.V. contrast enhancement may be ordered and additional images are
obtained.
 The patient is assessed carefully for adverse effects to the contrast medium.
IMPLICATIONS OF ABNORMAL RESULTS:
 Score of O: No plaque is present.
 Score between 1-10: a minimal amount of plaque is present.
 Score between 11-100: evidence of plaque is present. (Mild or minimal coronary narrowing).
 Score between 101 and 400: signifies moderate amount of calcified plaque in the arteries (an increased risk of
MI)
 Score >400: reveals extensive calcification and significant narrowing of the arteries due to plaque
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Informed Consent. Obtain an informed consent properly signed.
 Look for allergies. Assess for any history of allergies to iodinated dye or shellfish if contrast media is to be
used.
 Get health history. Ask the patient about any recent illnesses or other medical conditions and current
medications being taken. The specific type of CT scan determines the need for an oral or I.V. contrast medium
 Check for NPO status. Instruct the patient to not to eat or drink for a period amount of time especially if a
contrast material will be used.
 Get dressed up. Instruct the patient to wear comfortable, loose-fitting clothing during the exam.
 Provide information about the contrast medium. Tell the patient that a mild transient pain from the needle
puncture and a flushed sensation from an I.V. contrast medium will be experienced.
 Instruct the patient to remain still. During the examination, tell the patient to remain still and to
immediately report symptoms of itching, difficulty breathing or swallowing, nausea, vomiting, dizziness, and
headache.
 Diet as usual. Instruct the patient to resume the usual diet and activities unless otherwise ordered.
 Encourage the patient to increase fluid intake (if a contrast is given). This is so to promote excretion of
the dye.
G. MRI
DEFINITION:
 Magnetic resonance imaging (MRI) is a medical imaging technique that uses a magnetic field and computer-
generated radio waves to create detailed images of the organs and tissues in your body.
PURPOSE:
 MRI is a noninvasive way for your doctor to examine your organs, tissues and skeletal system. It produces
high-resolution images of the inside of the body that help diagnose a variety of problems.
INDICATIONS:
 After 4 to 6 weeks of leg pain, if the pain is severe enough to warrant surgery
 After 3 to 6 months of low back pain, if the pain is severe enough to warrant surgery
 If the back pain is accompanied by constitutional symptoms (such as loss of appetite, weight loss, fever, chills,
shakes, or severe pain when at rest) that may indicate that the pain is due to a tumor or an infection
 For patients who may have lumbar spinal stenosis and are considering an epidural injection to alleviate painful
symptoms
 For patients who have not done well after having back surgery, specifically if their pain symptoms do not get
better after 4 to 6 weeks.
CONTRAINDICATIONS/PRECAUTIONS:
 Patients who have a heart pacemaker may not have an MRI scan
 Patients who have a metallic foreign body (metal sliver) in their eye, or who have an aneurysm clip in their
brain, cannot have an MRI scan since the magnetic field may dislodge the metal
 Patients with severe claustrophobia may not be able to tolerate an MRI scan, although more open scanners are
now available, and medical sedation is available to make the test easier to tolerate
 Patients who have had metallic devices placed in their back (such as pedicle screws or anterior interbody
cages) can have an MRI scan, but the resolution of the scan is often severely hampered by the metal device and
the spine is not well imaged.
INTERFERRING FACTORS:
 Due to the use of the strong magnet, special precautions must be taken to perform an MRI on patients with
certain implanted devices such as pacemakers or cochlear implants. The MRI technologist will need some
information from you regarding the implanted device, such as the make and model number, to determine if it is
safe for you to have an MRI. Patients who have internal metal objects, such as surgical clips, plates, screws or
wire mesh, might not be eligible for an MRI.
 If there is a possibility that you are claustrophobic, then you can ask your physician to provide you with anti-
anxiety medication to take prior to your MRI examination. You should plan to have someone drive you home
after the MRI.
 If you are pregnant or suspect that you may be pregnant, you should notify your health care provider. To date
there is no information indicating that MRI is harmful to an unborn child, however MRI testing during the first
trimester is discouraged.
PATIENT PREPARATION:
 The medical staff will need to know if you have any metal in your body, including:
 inner ear implants
 artificial joints
 a defibrillator or pacemaker
 particular types of heart valves
 vascular stents
 brain aneurysm clips
 EAT/DRINK: You may eat, drink and take medications as usual.
 CLOTHING: You must completely change into a patient gown and lock up all personal belongings. A locker
will be provided for you to use. Please remove all piercings and leave all jewelry and valuables at home.
 WHAT TO EXPECT: Imaging takes place inside of a large tube-like structure, open on both ends. You must
lie perfectly still for quality images. Due to the loud noise of the MRI machine, earplugs are required and will
be provided.
 ALLERGY: If you have had an allergic reaction to contrast that required medical treatment, contact your
ordering physician to obtain the recommended prescription. You will likely take this by mouth 24, 12 and two
hours prior to examination.
 ANTI-ANXIETY MEDICATION: If you require anti-anxiety medication due to claustrophobia, contact your
ordering physician for a prescription. Please note that you will need some else to drive you home.
 STRONG MAGNETIC ENVIRONMENT: If you have metal within your body that was not disclosed prior
to your appointment, your study may be delayed, rescheduled or cancelled upon your arrival until further
information can be obtained.
NORMAL VALUES:
 Tissue signals and relaxation times reveal normal soft tissue structures of the brain, spinal cord, subarachnoid
spaces (limbs, joints, fat, muscles, tendons, ligaments, nerves, blood vessels, and marrow), heart, abdomen,
and pelvis (particularly liver, pancreas, spleen, adrenals, kidneys, and reproductive organs)
 Blood vessels: Normal size, anatomy, and hemodynamics
PROCEDURE:
 During the exam, it’s important to stay still to obtain the clearest images. Children who have difficulty staying
still may need sedation, administered either orally or through an IV line. Sedation can also be helpful for adults
who are claustrophobic.
 You will lie down on a table that slides into the MRI machine. The table slides through a large magnet shaped
like a tube. You may have a plastic coil placed around your head. After the table slides into the machine, a
technician will take several pictures of your brain, each of which will take a few minutes. There will be a
microphone in the machine that allows you to communicate with staff.
 The test normally takes 30 to 60 minutes. You may receive a contrast solution, usually gadolinium, through an
IV to allow the MRI machine to see certain parts of your brain more easily, particularly your blood vessels.
The MRI scanner will make loud banging noises during the procedure. You may be offered earplugs to block
the MRI machine’s noises, or you may listen to music during the test.
IMPLICATIONS OF ABNORMAL RESULTS:
 MRI of brain/skull demonstrates white matter disease (multiple sclerosis, infections, AIDS), neoplasms,
ischemia, cerebrovascular accident, aneurysms, hemorrhage; this is the test of choice to evaluate bone lesions
and fractures.
 MRI of spine demonstrates disc herniation, degenerations, neoplasms (primary and metastatic), inflammatory
disease, and congenital abnormalities. No spinal contrast is needed.
 MRI of limbs and joints demonstrates neoplasms, ligament or tendon damage, osteonecrosis, bone marrow
disorders, changes in blood flow.
 MRI of heart (cardiac MRI) demonstrates abnormal chamber size and myocardial thickness, valves and
coronary vessels, tumors, congenital heart disorders, pericarditis, graft patency (cardiac), thrombic disorders,
aortic dissection, and cardiac ischemia.
 MRI of abdomen and pelvis demonstrates neoplasms; especially useful in staging tumors, and tumor stage of
abdominal organs (liver, pancreas, adrenals, spleen, kidneys), blood vessels, and abnormalities of renal
transplants.
 MRI angiography (reference to noninvasive angiography) demonstrates aneurysms, stenosis, occlusions, graft
patency, and vascular malformations.
 Functional MRI evaluates brain function while the patient is engaged in a task (such as finger tapping) or
experiencing an auditory stimulus (such as music) and may demonstrate abnormalities related to dementia,
seizures, tumors, or strokes.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 No special post procedural care needed.
 Instruct patient to report any nausea, vomiting, or headache to the physician, in as much as this may be an
adverse effect to the injection
H. CARDIAC CATHETERIZATION
DEFINITION:
 Cardiac catheterization is an invasive procedure used to evaluate and treat heart conditions. A thin, long,
flexible tube is inserted, usually in the arm or groin, and is guided to the blood vessels of your heart.
PURPOSE:
 Cardiac catheterization allows your doctor to access your coronary arteries for blockages and to assess heart
muscle function and the structure and function of your heart valves. The catheterization procedure can also be
used to deliver therapy for many cardiac conditions.
INDICATIONS:
 Atherosclerosis
 Cardiomyopathy
 Congenital heart disease
 Heart failure
 Heart valve disease
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 An allergic reaction to the dye: This can cause flushing, a rash, extreme shortness of breath, hypertension or
hypotension, or heart rhythm irregularities and is treated as an emergency, usually with epinephrine.
 Artery damage: This can occur in any artery between the location of catheter insertion all the way to the
arteries in the heart, causing a defect called a pseudoaneurysm.10
 Perforation of the heart wall: This can cause a life-threatening condition, cardiac tamponade.
 Sudden blockage of a coronary artery, which can lead to a heart attack
 Extensive bleeding
 Stroke
EQUIPMENTS:
 You will need a blood count to screen for infection. A non-emergency cardiac catheterization is likely to be
postponed until you recover from an infection.
 You will need a PT/PTT, blood tests that assess your blood clotting factors.
 You will likely need to have an ECG to assess your heart rhythm and function, because a cardiac
catheterization may be riskier if you have an arrhythmia or weak heart function.
 You will likely have a chest X-ray to screen for major anatomical variations around your heart and lungs,
which prepares your doctors in case your procedure will be particularly challenging.
NORMAL VALUES:

PROCEDURE:
 Before the cath procedure, a nurse will put an IV (intravenous) line into a vein in your arm so you can get
medicine (sedative) to help you relax, but you’ll be awake and able to follow instructions during the procedure.
 The nurse will clean and shave the area where the doctor will be working. This is usually in the groin area.
 A local anesthetic is usually given to numb the needle puncture site.
 The doctor will make a needle puncture through your skin and into a large blood vessel. A small straw-sized
tube (called a sheath) will be inserted into the vessel. The doctor will gently guide a catheter (a long, thin tube)
into your vessel through the sheath. A video screen will show the position of the catheter as it is threaded
through the major blood vessels and to the heart. You may feel some pressure in your groin, but you shouldn’t
feel any pain.
 Various instruments may be placed at the tip of the catheter. They include instruments to measure the pressure
of blood in each heart chamber and in blood vessels connected to the heart, view the interior of blood vessels,
take blood samples from different parts of the heart, or remove a tissue sample (biopsy) from inside the heart.
 When a catheter is used to inject a dye that can be seen on X-rays, the procedure is called angiography.
 When a catheter is used to clear a narrowed or blocked artery, the procedure is called angioplasty or a
percutaneous coronary intervention (PCI).
 When a catheter is used to widen a narrowed heart valve opening, the procedure is called valvuloplasty.
 The doctor will remove the catheters and the sheath. Your nurse will put pressure on the site to prevent
bleeding. Sometimes a special closure device is used. The procedure lasts about an hour.
IMPLICATIONS OF ABNORMAL RESULTS:
 Bruising
 Bleeding
 Heart attack
 Stroke
 Damage to the artery, heart or the area where the catheter was inserted
 Irregular heart rhythms (arrhythmias)
 Allergic reactions to the dye or medication
 Kidney damage
 Infection
 Blood clots
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Educate patient that his/her bedrest might be shorter if the doctor placed a closure device.
 Check blood pressure while patient is lying in bed, sitting, and standing
 Instruct patient to move slowly when getting up from the bed to avoid any dizziness from the long period of
bedrest.
 Encourage patient drink plenty of water and other fluids to help flush the contrast dye from body.
ILLUSTRATE THE SITE OF INSERTION AND PATHWAY OF THE CATHETER IN THE RIGHT
AND LEFT HEART CATHETERIZATION:

I. ANGIOGRAPHY
DEFINITION:
 Angiography is an imaging test that uses X-rays to view your body’s blood vessels. The X-rays provided by an
angiography are called angiograms.
PURPOSE:
 This test is used to study narrow, blocked, enlarged, or malformed arteries or veins in many parts of your body,
including your brain, heart, abdomen, and legs.
INDICATIONS:
 Peripheral vascular disease
 Renovascular disease
 Transarterial cancer therapy (e.g. chemotherapy and radio frequency ablation)
 Mesenteric angina
 Cerebrovascular disease
 Subarachnoid haemorrhage from ruptured berry aneurysm requiring coil embolisation
 Elective embolisation
 Dialysis fistula mapping and maintenance angioplasty
 Central vascular disease
 Trauma
CONTRAINDICATIONS/PRECAUTIONS:
 Pregnancy or possible pregnancy (unless there is life-threatening haemorrhage or threat of same e.g. bleeding
from placenta accreta).
 Significant previous allergic reactions to iodinated contrast medium injection e.g. iohexol, iopamidol. These
includes acute breathlessness due to bronchospasm, laryngospasm, and swelling of the tongue and oropharynx,
cardiovascular collapse, and any reaction requiring emergency medical resuscitation (certain previous allergic
reactions can be managed by pre-treatment with steroids and antihistamines, or by using carbon dioxide
angiography).
 Renal impairment or dehydration. Additional contrast medium burden might lead to a deterioration in renal
function.
 Coagulopathy (especially INR > 2, aPTT ratio > 2, platelet count < 50,000 x 10–6). This could be a
consequence of chemotherapy, liver disease or haematological disease. With the advent of artery closure
devices, the contraindications of underlying coagulopathy are fewer than was historically the case.
 Antiplatelet or blood thinning medication.
 In diabetic patients treated with metformin who have pre-existing renal impairment or might have large doses
of contrast medium during the procedure, there is an increased risk of deteriorating renal function and lactic
acidosis after angiography. Metformin should be stopped on the day of the procedure until 48 hours after
angiography (using other treatments to control the patient’s diabetes). It can then be restarted if blood tests
show no deteriorating renal function (see: RANZCR Guidelines for Iodinated contrast administration, 2009).
 Excessive anxiety (might require general anaesthesia).
 Inability to lie flat or still (might require general anaesthesia).
INTERFERRING FACTORS:
 Heart attack
 Stroke
 Injury to the catheterized artery
 Irregular heart rhythms (arrhythmias)
 Allergic reactions to the dye or medications used during the procedure
 Kidney damage
 Excessive bleeding
 Infection
EQUIPMENTS:
 An angiography system comprises a patient table with an X-ray tube and detector suspended over it for
creating still or video images of the body as a contrast medium is administered. Some machines also include a
dedicated operating table for the simultaneous performance of surgery.
PATIENT PREPARATION:
 Your healthcare provider will explain the procedure to you. Ask him or her any questions you have. You may
be asked to sign a consent form that gives permission to do the procedure. Read the form carefully. Ask
questions if anything is not clear.
 Tell your healthcare provider if you:
 Are pregnant or think you may be pregnant
 Are allergic to contrast dye or iodine
 Have kidney failure or other kidney problems
 Are sensitive to or allergic to any medicines, latex, tape, or anesthetic medicines (local and
general)
 Take any medicines, including prescriptions, over-the-counter medicines, vitamins, and herbal
supplements
 Have had a bleeding disorder
 Take blood-thinning medicine (anticoagulant), aspirin, or other medicines that affect blood
clotting
NORMAL VALUES:
PROCEDURE:
 You may be asked to remove your clothes. If so, you will be given a hospital gown to wear. You may be asked
to remove jewelry or other objects.
 You’ll need to empty your bladder before the procedure.
 You will lie on your back) on the X-ray table.
 An intravenous (IV) line will be put in your arm or hand.
 Small sticky pads (electrodes) will be put on your chest. They will connect with wires to a machine (ECG) that
records the electrical activity of your heart. Your heart rate, blood pressure, and breathing will be watched
during the procedure.
 Hair at the site of the catheter insertion in the groin or arm may be trimmed. The skin will be cleaned. A
numbing medicine (local anesthetic) will be injected into the area.
 A thin, flexible tube (catheter) will be put in the groin or arm. The catheter will be gently guided through the
vein to the right side of the heart. Fluoroscopy may be used during this process to help get the catheter to the
right place.
 Contrast dye will be injected into your IV line. You may feel some effects when this is done. These effects
may include a flushing sensation, a salty or metallic taste in the mouth, a brief headache, nausea, or vomiting.
These effects usually last for a few moments. Tell the radiologist if you feel any trouble breathing, sweating,
numbness, or heart palpitations.
 After the contrast dye is injected, a series of X-ray images will be taken. In some cases, more contrast dye may
be injected and more X-ray images taken.
 The groin or arm catheter will be removed. Pressure will be applied over the area to stop bleeding.
 A dressing will be applied to the site. A small, soft weight may be placed over the site for a period of time.
This is to prevent more bleeding or a hematoma at the site.
IMPLICATIONS OF ABNORMAL RESULTS:
 Myocardial infarction
 Septic shock
 Multiple organ dysfunction
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Assess vital signs, catheterization site for bleeding or hematoma, peripheral pulses, and neurovascular status
every 15 minutes for first hour, every 30 minutes for the next hour, then hourly for 4 hours or until discharge.
The data provide vital information about the client’s status and potential complications such as bleeding,
hematoma, or thrombus formation.
 Maintain bed rest as ordered, usually for 6 hours if the femoral artery is used, or 2 to 3 hours if the brachial site
is used. The head of the bed may be raised to 30 degrees. Bed rest reduces movement of and pressure in the
affected artery, reducing the risk of bleeding or hematoma.
 Keep a pressure dressing, sandbag, or ice pack in place over the arterial access site. Check frequently for
bleeding (if the access site is in the groin, check for bleeding under the buttocks). Arteries are high-pressure
systems. The risk for significant bleeding after an invasive procedure is high.
 Instruct to avoid flexing or hyperextending the affected extremity for 12 to 24 hours. Minimizing movement of
the affected joint allows the artery to effectively seal and promotes blood flow, reducing the risk of bleeding,
hematoma, or thrombus formation.
 Unless contraindicated, encourage liberal fluid intake. An increased fluid intake promotes excretion of the
contrast medium, reducing the risk of toxicity (particularly to the kidneys).
 Promptly report diminished peripheral pulses, formation of a new hematoma or enlargement of an existing one,
severe pain at the insertion site or in the affected extremity, chest pain, or dyspnea. While the risk of
complications is low, myocardial infarction or insertion site complications may occur. These necessitate
prompt intervention.
 Provide instructions about dressing changes, follow-up appointments, and potential complications prior to
discharge.
J. AORTOGRAPHY
DEFINITION:
 Aortography is an angiographic method of examination. Angiography refers to the production of x-ray images
of blood vessels after a contrast agent has been added to the bloodstream.
PURPOSE:
 It is used to diagnose diseases of the aorta, such as an aortic aneurysm. For the examination, a catheter is used
to administer an x-ray contrast agent into the aorta.
INDICATIONS:
 Nonselective visualization of the coronary arteries if selective engagement was unsuccessful
 Images Nonselective visualization of coronary bypass grafts if selective engagement was not successful
 Images Aortic regurgitation
 Images Aortic valve stenosis
 Images Aortic aneurysm/aortic dissection
 Images Before endovascular repair of a dissection
 Images Sinus of Valsalva aneurysm
 Images Coarctation of the aorta
 Images Congenital malformations, for example, aortopulmonary septal defect, anomalous origins of supra-
aortic vessels
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 This is generally a low-risk examination. Bruising may occur at the site where the catheter enters the artery
(cannulation site). The administration of the contrast agent may cause a warm sensation; however, this is
generally not perceived as unpleasant. Damage to the aorta or temporary cardiac arrhythmias are rare.
EQUIPMENTS:
 Prior to the examination, the patient’s medical history is reviewed to establish whether they are hypersensitive
to x-ray contrast agents. A blood test is also carried out to check their kidney function. The patient may need
to stop taking blood-thinning medication before the examination.
NORMAL VALUES:
PROCEDURE:
 To perform this procedure, your doctor will inject a dye into your arteries in order to view them by X-ray.
Your doctor will make a small incision in your groin and install a short plastic tube called a sheath to keep the
incision open. Through this hole, your doctor will insert a thin tube, or catheter, and guide it up through your
arteries into your aorta.
 You shouldn’t feel any pain when the catheter is inserted since there are no nerve endings in your arteries.
 When your doctor reaches the appropriate part of your aorta, they will release dye through the catheter. As the
dye is released, your doctor will watch how it travels through your arteries on X-ray, looking for any
blockages, changes in the aorta, or abnormal blood flow.
 The angiogram takes about an hour. Once the catheter is removed, pressure will be applied to the area to
prevent excessive bleeding and a bandage will be applied. Afterward, you’ll recover in a separate room and
will have to lie flat for several hours to prevent bleeding. You will be monitored to ensure there aren’t any
complications and will be given plenty of fluids to help flush the dye out of your system.
IMPLICATIONS OF ABNORMAL RESULTS:
 Abdominal aortic aneurysm
 Aortic dissection
 Aortic regurgitation
 Aortic stenosis
 Congenital (present from birth) problems
 Double aortic arch
 Coarction of the aorta
 Vascular ring
 Injury to the aorta
 Mesenteric ischemia
 Peripheral artery disease
 Renal artery stenosis
 Takayasu arteritis
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 The radiologist or nurse will remove the catheter and hold the site for 15 to 20 minutes to prevent bleeding. If
the catheter was in your groin, you will need to lie flat without raising your leg for about four hours.
 The head of the bed may be tilted a little to help you rest. Your nurse will help you with any personal needs.
 Your nurse will check your blood pressure, heart rate, heart rhythm, and pulse in the area near the catheter
insertion.
K. CORONARY ARTERIOGRAPHY
DEFINITION:
 Coronary arteriography is a procedure in which a very thin catheter, or tube, is threaded through an artery
from the groin, neck, or arm to the coronary arteries around the heart. The doctor uses this catheter to put a
contrast dye into the blood of the coronary arteries. The dye shows up on X-rays and highlights the coronary
arteries. The X-rays are called angiograms.
PURPOSE:
 To find out if you have a blockage in a coronary artery. Your doctor will be concerned that you’re at risk of a
heart attack if you have unstable angina, atypical chest pain, aortic stenosis, or unexplained heart failure.
INDICATIONS:
 Patients with atypical chest pain, in whom the diagnosis cannot be established in any other way may be
subjected to this procedure, particularly if they are young, if the pain appears disabling, or if their occupation
makes them responsible for the lives of other persons (airline pilots, bus drivers and the like).
 Patients with disabling angina, preferably of long duration and unresponsive to a good medical regimen, are
the prime potential candidates for surgical treatment and represent the largest group subjected at present to
coronary arteriography.
 Patients who underwent surgical treatment may be subjected to visualization of the bypass graft or of the
coronary arterial tree or both. This not only permits the evaluation of the operation, but is of benefit to the
person with regard to prognosis and the possibility of further operation.
 Young persons with repeated, proven myocardial infarcts constitute a potential surgical group, even if they
happen to be asymptomatic. The occurrence of two or three myocardial infarcts in short succession suggests
accelerated coronary artery disease, in which operation may be justifiable even if long-range results are as yet
unknown.
 Patients who are to have open heart operations and who are suspected or known to have ischemic heart
disease should have coronary arteriography before the operation.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Injection of the concentrated heparin solution directly into a coronary artery must be avoided as this is very
likely to cause ventricular fibrillation.
 A DC external defibrillator was in the room at all times and prepared for immediate use before the procedure
was begun.
 Isordil (5 mg. sublingual) and, if neces- sary, nitroglycerin (grain i/iso sublingual) were given freely if angina
was noted during the procedure. Usually, it did not occur unless the patient was incorrectly placed in a
strained position.
 Bradycardia and asystole for several seconds were seen rather frequently, especially after injection of the right
coronary artery. These changes were promptly re- versed by having the patient give a small cough. Nausea
was noted occasionally before or after injection. It consistently re- sponded promptly to inhalation of pure
oxygen. For some reason, nausea has been noted much more frequently in patients who turned out to have
normal coronary arteries.
 There usually was no subjective sensation during injection of the medium into a coronary artery. A burning in
the neck for several seconds was the most commonly re- ported sensation, if any. Injection of 10 cc. in the
cusp was usually felt, but rarely caused much discomfort. Injection of the medium into the subclavian artery
was quite painful.
EQUIPMENTS:
 Sones catheter attached to rotate device (Becton-Dickinson") to allow free rotation of catheter.
 T-adapter (Becton-Dickinson) connecting pressure transducer G to injection line to allow constant pressure
recording during angiography. This eliminates need for manipulating stopcocks to obtain pressures between
injections.
 Plastic tubing connecting reservoir of contrast medium with injection syringe by means of a special one-way
valve.
 Reynolds injection syringe. Pressure on lever lying superiorly (arrow) injects up to 10 ml. of contrast
medium. Pressure on opposite side of same level refills syringe. It will also refill automatically, but more
slowly.
 Pressure tubing to tank of compressed CO, (or air) to provide motive power for syringe. Reducing valve
gauge is usually set at 35 pounds per square inch; for cusp injection, pressure may be increased to 45 pounds
per square inch.
 Plastic tubing connecting transducer to external mercury manometer for calibration.
 Statham strain-gauge transducer.
 Cable between transducer and recording system.
NORMAL VALUES:
PROCEDURE:
 DURING THE PROCEDURE
 Lie the client on their back on an X-ray table. Because the table may be tilted during the procedure, safety
straps may be fastened across their chest and legs.
 An IV line is inserted into a vein in their arm. They may be given a sedative through the IV to help you
relax, as well as other medications and fluids.
 Electrodes on their chest monitor your heart throughout the procedure. A blood pressure cuff tracks your
blood pressure and another device, a pulse oximeter, measures the amount of oxygen in your blood.
 A small amount of hair may be shaved from the client’s groin or arm where a flexible tube (catheter) will
be inserted. The area is washed and disinfected and then numbed with an injection of local anesthetic.
 A small incision is made at the entry site, and a short plastic tube (sheath) is inserted into the client’s
artery. The catheter is inserted through the sheath into their blood vessel and carefully threaded to their
heart or coronary arteries. Note: Threading the catheter shouldn't cause pain, and you shouldn't feel it
moving through your body.
 Dye (contrast material) is injected through the catheter.
 Having an angiogram takes about one hour, although it may be longer, especially if combined with other
cardiac catheterization procedures. Preparation and post-procedure care can add more time.
 AFTER THE PROCEDURE
 When the angiogram is over, the catheter is removed from the client’s arm or groin and the incision is
closed with manual pressure, a clamp or a small plug.
 The client will be taken to a recovery area for observation and monitoring. When your condition is stable,
you return to your own room, where you're monitored regularly.
 The client need to lie flat for several hours to avoid bleeding if the catheter was inserted in the groin.
During this time, pressure may be applied to the incision to prevent bleeding and promote healing.
 The client may be able to go home the same day, or you may have to remain in the hospital overnight.
Drink plenty of fluids to help flush the dye from your body. If you're feeling up to it, have something to
eat.
 Inform the client when to resume taking medications, bathing or showering, working, and doing other
normal activities and to avoid strenuous activities and heavy lifting for several days.
 Inform the client that the puncture site is likely to remain tender for a while. It may be slightly bruised
and have a small bump.
IMPLICATIONS OF ABNORMAL RESULTS:
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
L. ELECTROPHYSIOLOGIC TESTING
DEFINITION:
 Electrophysiologic study involves the introduction of an electrode catheter under fluoroscopy through a
peripheral vein or artery and into the cardiac chambers or sinuses and the performance of programmed
electrical stimulation of the heart.
PURPOSE:
 To document the anatomy and physiologic substrates of episodic dysrhythmias by reproducing them so that the
mechanism can be identified. Helps diagnose cardiac conduction defects, circuit reentry, ectopic foci, syncope
of unexplained cause, tachydysrhythmias, and ventricular pre-excitation syndromes; evaluates the
effectiveness of anti-dysrhythmic medications or ablation; helps determine proper choice of a pacemaker;
maps the cardiac conduction system before ablation; determines the need for an implanted defibrillator to
prevent sudden cardiac death; and records intracardiac electrocardiograms.
INDICATIONS:
 Indications for EP testing vary depending on the age of the child, the underlying cardiac anatomy, and the
suspected arrhythmia.
 Patients with incessant Supra-ventricular tachycardia who show signs of ventricular dysfunction
 Patients with Wolf-Parkinson-White syndrome who have had syncope or near-miss sudden death
 Patients with VT and hemodynamic compromise.
 Asymptomatic WPW in children > 5yrs
 SVT in children > 5 yrs. when medications are effective, and SVT in children <5 yrs. where medications
are ineffective or show side effects.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Bleeding disorders
 thrombocytopenia.
 Sedatives are contraindicated in clients with central nervous system depression
EQUIPMENTS:
PATIENT PREPARATION:
• Antidysrhythmic drugs are usually discontinued for several days before the test, when tolerated, for initial
EPS. For evaluation of effectiveness of antidysrhythmic therapy, drug levels should reach a steady state before
EPS. This may take several days or even a few weeks for drugs such as amiodarone.
• The client should fast from food overnight and from fluids for 4 hours before the test. Establish intravenous
access.
• If left ventricular stimulation that requires an arterial EPS route is planned, preheparinization may be
prescribed.
• Have emergency cart and defibrillator or cardioverter readily available. A sedative may be prescribed.
• Obtain baseline vital signs. Monitor vital signs and level of consciousness continuously throughout the
procedure. Observe respiratory status closely throughout the procedure, especially if a sedative is administered.
• Just before beginning the procedure, take a “time out” to verify the correct client, procedure, and site
NORMAL VALUES:
PROCEDURE:
• During procedure
 The client is positioned on the procedure table, and the peripheral pulses distal to the insertion site are
marked. The location and baseline quality of the pulses are documented.
 A baseline electrocardiogram is obtained. The leads are left in place for continuous cardiac monitoring.
 The insertion site is cleansed with povidone-iodine solution, allowed to dry, and draped.
 An introducer (sheath, Cordis) catheter is introduced, using the Seldinger technique, through a femoral,
brachial, subclavian, or jugular vein. An arterial approach is used for stimulation of the left ventricle. A
size 5F, 6F, or 7F electrode catheter is advanced under fluoroscopy tthe heart.
 Intracardiac electrocardiograms are recorded.
 After proper catheter position is verified, the following or any combination may be performed, depending
on the purpose of the study (an amnestic such as midazolam may be administered before induction of
dysrhythmias):
Mapping of the electrical system and pathways, with characterization of the electrical properties of the
cardiac conduction system.
Measurement of conduction times, refractory periods, and recovery times of different portions of the
heart.
Pacing of the atria may be performed, and extra stimuli may be added at specific intervals, to evaluate
whether they can stimulate dysrhythmias.
Attempts to induce dysrhythmias by delivery of a small electrical charge to specific locations of the
chamber walls.
Overdrive pacing.
Antidysrhythmic drug effectiveness may be evaluated by administration of the drug to terminate
stimulated dysrhythmias.
 Induced dysrhythmias that are poorly tolerated (that is, cause hypotension, loss of consciousness) may be
terminated by overdrive pacing, cardioversion, or defibrillation.
 The catheter is removed, and pressure is applied to the site for 10 minutes, or at least until 10 minutes after
bleeding stops. A pressure dressing is placed over the site.
IMPLICATIONS OF ABNORMAL RESULTS:
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Assess and document the following every 15 minutes × 4, then every 30 minutes × 4, then hourly × 4, and then
every 4 hours until 24 hours after the procedure:
 Vital signs.
 Insertion site for bleeding or hematoma.
 Color, motion, temperature, sensation, and the presence and quality of pulses in the extremity distal to the
insertion site as compared to baseline value, and those for the opposite extremity. Notify the physician of
any changes from baseline assessment.
 If deep sedation was used, follow institutional protocol for post sedation monitoring. Typical monitoring
includes continuous ECG monitoring and pulse oximetry, with continual assessments (every 5-15 minutes) of
airway, vital signs, and neurologic status until the client is lying quietly awake, is breathing independently, and
responds appropriately to commands spoken in a normal tone.
 For bleeding at insertion site, apply firm pressure for 10 minutes. If bleeding continues after 10 minutes,
continue holding pressure, and notify physician.
 A sandbag may be placed over the insertion site for several hours.
 Maintain continuous electrocardiographic monitoring and observe for dysrhythmias for at least 24 hours.
 Resume diet.
 If antidysrhythmic drugs were administered during EPS or begun after EPS, observe cardiac monitor pattern
for their effect.
M. ARTERIOGRAM
DEFINITION:
 An arteriogram is a radiographic examination of arteries through which radiographic contrast medium is
flowing. The arteries are assessed for abnormalities in blood flow, such as narrowing or outpouching of the
walls, and for collateral circulation.
PURPOSE:
 Aids diagnosis of arterial occlusion,aneurysm, abnormal vascular development, hemorrhage and transient
ischemia attacks (TIAs). Helps identify areas of arterial narrowing caused by plaque buildup, degree of
stenosis after myocardial infarction (MI),tumor, or vascular abnormalities. Useful preoperatively to help
identify potential failing arterial bypass grafts.
INDICATIONS:
 Patients with angina pectoris
 Patients with angina pectoris with markedly positive stress test
 Patients with unstable angina pectoris • Patients with positive stress test following myocardial infarction •
The young patients with strong family history of coronary heart disease
 Variants of angina pectoris
 Preoperative evaluation of valvular heart disease
 Patients who have congestive heart failure
 Unresolved diagnostic problems
 Postoperative coronary bypass surgery
 Resuscitation from sudden cardiac death
 Certain asymptomatic patients
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Anticoagulant therapy
 Bleeding disorders
 Thrombocytopenia
 Dehydration
 Uncontrolled hypertension
 Previous allergy to radiographic dye, iodine, or shellfish, renal insufficiency, and pregnancy (if iodinated
contrast medium is used because of radioactive iodine crossing the blood-placental barrier)
EQUIPMENTS:
PATIENT PREPARATION:
 If the abdominal vasculature is to be examined, a cathartic may be administered 1 day before the test and a tap
water enema may be given on the morning of the test.
 Consume clear liquids only for 24 hours and fast from food and fluids for 8 hours before the test.
 It is normal to experience a brief flushing sensation and possibly nausea when the dye is injected, but the
feeling will pass quickly.
 It is important to lie still throughout the procedure.
 Bed rest and frequent site and extremity checks are performed as standard postprocedure care.
 In women who are breast-feeding, formula should be substituted for breast milk for 1 or more days after the
procedure.
 Obtain baseline CBC, PT, and APTT values. Remove all jewelry and metal objects.
 The client should void just before the procedure.
 Obtain baseline vital signs, and mark peripheral pulses. Have emergency equipment readily available for
anaphylaxis and cardiac arrest.
 Just before beginning the procedure, take a “time out” to verify the correct client, procedure and site.
NORMAL VALUES:
PROCEDURE:
 Client is placed supine on the radiograph table.
 A maintenance intravenous line is started.
 The peripheral pulses are marked, and the extremity is immobilized.
 The femoral or brachial artery area is located and cleansed with povidoneiodine solution and allowed to dry,
and the surrounding area is covered with a sterile drape.
 A local anesthetic (1% to 2% lidocaine) is injected intradermally and subcutaneously over the artery.
 The femoral or brachial artery is punctured with a large-bore needle. A wire is passed through the needle and
the needle removed over the guidewire.
 The catheter is then inserted into the artery over the guidewire, and placement is confirmed by fluoroscopy.
 The catheter is advanced under fluoroscopy to a location depending on the area to be examined, and
radiographic dye is injected.
 Several rapid radiographic pictures are taken of the artery and its branches during and after dye injection.
 The catheter is removed, and sterile gauze is applied immediately, with pressure, to the site for at least 15
minutes.
IMPLICATIONS OF ABNORMAL RESULTS:
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Apply pressure dressing to arterial puncture site.
 The client remains on bed rest with the affected extremity immobilized for 12 hours.
 Assess the site and dressing for hematoma or bleeding; the distal pulses for presence and strength; and color,
motion, temperature, and sensation of the affected extremity every 15 minutes × 4, every half hour × 4, then
every hour × 4, and then every 4 hours.
 Apply pressure for at least 15 minutes if bleeding occurs.
 Encourage oral intake of fluids if not contraindicated.
N. VENOGRAM
DEFINITION:
 Venography or venogram is an invasive, radiographic, or nuclear medicine procedure whereby radiopaque dye
or a radionuclide is injected intravenously and the lower extremities are radiographed for the DVT.
PURPOSE:
 Detection of site and presence of venous thrombosis of the lower extremities
 Radiographic guidance for insertion of peripherally inserted central catheter (PICC)
 Used with magnetic resonance imaging for the detection and evaluation of arteriovenous malformations and
vascular venous lesions.
INDICATIONS:
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Severe congestive heart failure
 Severe pulmonary hypertension
 Previous allergy toradiographic dye, iodine, or shellfish; pregnancy (because of the radioactive iodine crossing
the blood-placental barrier)
 Renal insufficiency.
EQUIPMENTS:
PATIENT PREPARATION:
 This test is normally performed in a radiology department.
 Have emergency equipment readily available.
 Obtain radiographic dye, heparin and saline flush solution, and a tourniquet.
 Just before beginning the procedure, take a “time out” to verify the correct client, procedure, and site.
NORMAL VALUES:
PROCEDURE:
 The client is positioned supine or semiupright on the fluoroscopic table, with the weight placed on the
nonexamined extremity.
 A tourniquet may be placed on the extremity to control the speed of blood flow.
 After intravenous access is established in a foot vein, radiographic dye is injected, and several rapid, sequential
radiographs are taken of the extremity as the dye flows in the bloodstream. Alternatively, one may conduct a
nuclear medicine study whereby a radionuclide is injected, followed by scintigraphic scanning of the
extremity.
 The intravenous access site is flushed with heparin/saline solution, and the access is removed.
IMPLICATIONS OF ABNORMAL RESULTS:
 An intraluminal filling defect in the deep venous contrast column indicates deep venous thrombosis (DVT).
 An abrupt cutoff of a deep vein with the development of collateral circulation may also indicate the presence
of DVT.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Assess injection site for symptoms of dye infiltration (redness, edema, warmth, tenderness).
 Assess vital signs; peripheral pulses; and color, motion, temperature, and sensation of lower extremities every
15 minutes × 4, then every 30 minutes × 4, then hourly × 4, and then every 4 hours until 24 hours after the
procedure.
O. HEMODYNAMIC MONITORING (CVP, PULMONARY ARTERY PRESSURE, INTRA-ARTERIAL BP
MONITORING)
DEFINITION:
 The study of forces involved in the flow of blood through the cardiovascular and circulatory systems can be
Non-invasive(blood pressure monitoring or mean arterial pressure) or Invasive (Used to make actual
measurements of pressures directly within the heart) (CVP, pulmonary artery pressure, intra-arterial BP
monitoring)
PURPOSE:
 Early detection, identification and treatment of life-threatening
 Conditions such as heart failure and cardiac tamponade
 Allow immediate evaluation of patient’s response to treatment such as drugs and mechanical support
INDICATIONS:
 Signs of severe dehydration, hemorrhage, G.I. bleed
 Burns or surgery
 All types of shock
 Any deficit or loss of cardiac function (such as AMI or CHF)
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Follow electrical safety monitoring guidelines
 Risk to patient: ventricular fibrillation
 A defibrillator, emergency crash cart and medications must be readily available
EQUIPMENTS:
 Amplifier – located inside the bedside monitor; increases the size of signal from the transducer
 Recorder or monitor – to display the signal and record information
 Transducer – changes the mechanical energy or the pressures of pulse into electrical energy
 Supplemental equipment Pressure tubing – prevents tubing distention
NORMAL VALUES:
 CVP: 2 to 6 mmHg
Pulmonary artery pressure:
 Systolic: 20-30 mmHg
 Diastolic: 10-15 mmHg
PROCEDURE:
 Set-Up Supplies
 Tighten all connections of monitoring kit.
 Spike the flush solution with the IV administration end of the monitoring kit.
 Flush the line in a systematic manner eliminating the air bubbles including those in all ports of each stopcock.
 Aseptically replace open-ended caps with protective (closed) male/female luer lock adapter (dead-ender).
 Attach the transducer to the monitor transducer cable. Plug the cable into the invasive pressure module in the
bedside monitor.
 Place the flush solution in the pressure bag and apply pressure to 300 mmHg.
 Zeroing
 Label pressure parameter appropriately. ‘ABP’ label must be used for the primary arterial waveform.
 Turn stopcock nearest to transducer OFF to patient.
 Remove the male/female luer lock adapter (dead-ender) aseptically from stopcock, which opens transducer to
air.
 Touch ZERO on monitor and wait until zeroing is confirmed
 Aseptically replace male/female luer lock adapter (dead-ender). Turn stopcock ON to patient. Note: If a Zero
Rejected message appears there is a transducer problem
 Level the transducer to the patient’s phlebostatic axis (fourth intercostal space at mid-anterior posterior line).
10. Set monitor alarms appropriate for patient condition based on nursing assessment. Note: Do not
permanently disable alarms due to risk of missing situation of disconnection of line and subsequent
hemorrhage
 Monitor the pressure system for:
 Appropriate scale
 Overdampened or underdampened waveform
 False high or low readings
 Inappropriate pressure waveform
 Blood back into tubing or transducer. Note: For trouble shooting of waveforms
 Documentation
 IV flush bags, line, dressing and date commenced on the appropriate record.
IMPLICATIONS OF ABNORMAL RESULTS:
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Assist with insertion and removal of invasive hemodynamic lines.
 Monitor heart rate and rhythm.
 Zero and calibrate equipment every 4 to 12 hours, as appropriate, with transducer at the level of the right
atrium to ensure accuracy of waveform.
 Monitor blood pressure (systolic, diastolic, and mean), central venous/right atrial pressure, pulmonary artery
pressure (systolic, diastolic, and mean), and pulmonary capillary/artery wedge pressure.
 Monitor hemodynamic waveforms for changes in cardiovascular function
 Compare hemodynamic parameters with other clinical signs and symptoms.
 Monitor pulmonary artery and systemic arterial waveforms; if dampening occurs, check tubing for kinks or air
bubbles, check connections.
 Document pulmonary artery and systemic arterial waveforms
 Monitor peripheral perfusion distal to catheter insertion site every 4 hours or as appropriate.
 Refrain from inflating balloon more frequently than every 1 to 2 hours, or as appropriate
 Maintain sterility of ports.
 Perform sterile dressing changes and site care, as appropriate.
 Inspect insertion site for signs of bleeding or infection.
 Change IV solution and tubing every 24 to 96 hours, based on protocol.
 Keep hemodynamic monitoring alarms ON.
P. CABG
DEFINITION:
 Coronary artery bypass grafting (CABG) is a procedure to improve poor blood flow to the heart. It may be
needed when the arteries supplying blood to heart tissue, called coronary arteries, are narrowed or blocked.
PURPOSE:
 Restore blood flow to the heart
 Relieves chest pain and ischemia
 Improves the patient's quality of life
 Enable the patient to resume a normal lifestyle
 Lower the risk of a heart attack
INDICATIONS:
 Restore blood flow to the heart
 Relieves chest pain and ischemia
 Improves the patient's quality of life
 Enable the patient to resume a normal lifestyle
 Lower the risk of a heart attack
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Aneurysms
 Valvular diseases
 Congenital diseases
 Diseases of blood
EQUIPMENTS:
 MICS Retractor System
 Nuvo Stabilizer
 NS Positioner
 Anastomotic Device
 Optional Rotating Extender Bar with Cross Square
 Small and Medium Endoscopic Clip Appliers
 Knot Pusher
 Minimally Invasive (MI) Needle Holder
 Minimally Invasive Curved Scissors
 Minimally Invasive Debakey Forceps
 14"Chest Tube Passer w/ Lock 12. Tangential Occlusion Clamp - 34 mm w/ DeBakey Atraumatic Jaws,
Slightly Curved
 DeBakey Aorta Clamp - Full Curved DeBakey Atraumatic Jaws, Curved Shanks, Stainless Steel,10.5 inch
 Soft Tissue Retractor
 16 and 18 Fr Red Rubber Catheter
 Extended Bovie Blade
 Femoral Cannula – Arterial
 Femoral Cannula – Venous
 Pain Pump
 Standard Off-Pump CABG tray
NORMAL VALUES:
PROCEDURE:
 An endotracheal tube is inserted and secured by the anaesthetist and mechanical ventilation is started. General
anaesthesia is maintained by a continuous very slow injection of Propofol.
 The chest is opened via a median sternotomy and the heart is examined by the surgeon involves creating a 6 to
8 inch incision in the chest (a thoractomy)
 The bypass grafts are harvested – frequent conduits are the internal thoracic arteries, radial arteries and
saphenous veins. When harvesting is done, the patient is given heparin to prevent the blood from clotting.
 "on-pump", the surgeon sutures cannulae into the heart and instructs the perfusionist to start cardiopulmonary
bypass (CPB). Once CPB is established, the surgeon places the aortic cross-clamp across the aorta and
instructs the perfusionist to deliver cardioplegia to stop the heart and slow its metabolism
 One end of each graft is sewn on to the coronary arteries beyond the blockages and the other end is attached to
the aorta.
 Chest tubes are placed in the mediastinal and pleural space to drain blood from around the heart and lungs
 The sternum is wired together and the incisions are sutured closed.
 The patient is moved to the intensive care unit (ICU) to recover.
 Nurses in the ICU focus on recovering the patient by monitoring blood pressure, urine output and respiratory
status as the patient is monitored for bleeding through the chest tubes. If there is chest tube clogging, Thus
nurses closely monitor the chest tubes and undertake methods to prevent clogging so bleeding can be
monitored and complications can be prevented.
 After awakening and stabilizing in the ICU (approximately one day), the person is transferred to the cardiac
surgery ward until ready to go home (approximately four days).
IMPLICATIONS OF ABNORMAL RESULTS:
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Assessment
 Patient history
 Physical Examination (head to toe)
 Pshycosocial Assesment
 Diagnostic procedure
 Access health care team availability
 Surgeon
 Anesthesia personnel
 Circulating nurse
 Scrub person
 Other personnel
 Informed consent
 Explain all treatment and procedure done for the patient answering any question patient may have .present
information at patient understanding level to reduce patient anxiety
 Orient patient to surrounding
 Assign the same nurse to care for patient whenever possible to provide consistency of care, enhance trust and
reduce threat often associated with multiple care givers.
 Spend time with patient each shift to allow time for expression of feelings, provide emotional outlet and
promote feeling of acceptance.
Q. GALLIUM SCAN
DEFINITION:
 Nuclear medicine scan of the liver using gallium-67 citrate radiopharmaceutical. Normal liver tissue will
absorb gallium in a symmetric fashion. Abscesses appear as a “rim sign,” heavily concentrated areas of
gallium uptake surrounding a cold center. The cold center is an area where no inflammation exists. Abscesses
are rich with lactoferrin in the neutrophils, and galliumappears to bind to the lactoferrin, making the abscess
visible. Tumors appear as heavily concentrated areas of gallium with normal symmetric gallium uptake in the
surrounding liver tissue
PURPOSE:
 Detection of hepatomas, abscesses, biopsy sites, and alcoholic cirrhosis and evaluation of recurrent lymphomas
or tumors after chemotherapy and radiation therapy.
INDICATIONS:
 Detection, localization, and follow-up of infection (sepsis with or without localized signs/symptoms, and
FUOs). • Detection and localization of tumors (staging and follow-up of the following:
 Lymphoreticular neoplasms (esp. Hodgkin's, histiocytic lymphoma
 Bronchogenic Ca.
 Hepatocellular Ca.
 Testicular Ca.
 Malignant melanoma.
 Evaluation of interstitial and chronic lung disease as well as sarcoid.
 Evaluation of patients with acquired immunodeficiency syndrome (AIDS).
 Evaluation of extent and/or effect of therapy in granulomatous (e.g., sarcoidosis).
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Previous allergic reaction to the same radiopharmaceutical. This test is usually contraindicated during
pregnancy and breast-feeding.
EQUIPMENTS:
PATIENT PREPARATION:
 The client is injected with a gallium- 67 citrate radiopharmaceutical intravenously 48-72 hours before the scan.
 Increase oral intake of fluids, where not contraindicated, 24 hours before the scan.
 A clear-liquid diet may be prescribed for the day before the test.
 Cleansing enemas may be prescribed the morning before the test.
 The camera will make clicking noises during the scan.
 The scan takes 30-60 minutes to perform.
 Drink 6-8 glasses of water and other fluids per day for 2 days (where not contraindicated) after the scan.
 Just before beginning the procedure, take a “time out” to verify the correct client, procedure, and site.
NORMAL VALUES:
PROCEDURE:
 The client is positioned either erect or recumbent under a gamma (Anger) camera or rectilinear scanner in the
nuclear medicine department.
 Serial images are obtained anteriorly and posteriorly, and occasionally lateral views may be required
 The client must lie motionless during the scan.
IMPLICATIONS OF ABNORMAL RESULTS:
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Remove jewelry or any metal objects that may hide X-ray visualization of the bones
 Additional imaging may be performed at 24-hour intervals to differentiate normal activity from pathologic
concentrations.
 No specific care is needed after the procedure.
R. THALLIUM SCAN
DEFINITION:
 A thallium (or cardiolite) scan uses a radioactive tracer to see how much blood is reaching different parts of
your heart
PURPOSE:
 Used to show myocardial perfusion, location, and extent of acute or chronic myocardial infarction or coronary
artery disease; also shows effectiveness of angioplasty, angina therapy, or grafted coronary arteries.
INDICATIONS:
 In patients who present with acute, stable chest pain
 Inferior and posterior abnormalities and small areas of infarction can be identified, as well as the occluded
blood vessels and the mass of infarcted and viable myocardium.
 In patients with known CAD
 Assessment of viable myocardium in a specific coronary artery distribution after a heart attack
 Post intervention revascularization (coronary artery bypass graft or angioplasty) evaluation
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Clients who are unable to lie motionless for the scan; women who are breast-feeding
 Previous allergic reaction to radiopharmaceutical or radiolabeled albumin if use is planned.
EQUIPMENTS:
PATIENT PREPARATION:
 Assess for history of hypersensitivity to radioactive dyes.
 Have emergency equipment readily available. This includes aminophylline to counteract the side effects of
dipyridamole if the dipyridamole test is to be performed.
 For scans conducted with stress testing, obtain a baseline 12-lead ECG.
 Do not take drugs or drink caffeine containing beverages for 6 hours before testing (24 hours for the SPECT
scan).
 Some tests take several hours. Bring reading material or other diversional activity.
 Thallium-201, MUGA, nitroglycerin: Report fatigue, pain, or shortness of breath immediately, particularly if
stress (exercise) is used.
 You may be asked to move into different positions during the scan.
 Drink plenty of fluids for 24 hours after the procedure.
 For positive results reduce modifiable risk factors: smoking cessation, dietary modification, maintain healthy
BP and cholesterol levels. Just before beginning the procedure, take a “time out” to verify the correct client,
procedure, and site.
NORMAL VALUES:
PROCEDURE:
 This test is done at a medical center or physician's office. It is done in parts, or stages
 The client will have an IV (intravenous line) started. 3. A radiopharmaceutical, such as thallium or sestamibi,
will be injected into one of the client’s veins
 Lie down the client and wait for between 15 and 45 minutes
 A special camera will scan the client’s heart and create pictures to show how the radiopharmaceutical has
traveled through their blood and into their heart.
 Let the client walk on treadmill
 After the treadmill starts moving slowly, asked the client to walk (or pedal) faster and on an incline. It is like
being asked to walk fast or jog up a big hill.
 If the client were not able to exercise, the doctor may give a vasodilator, which dilates your heart arteries. Or a
medicine that will make the client’s heart beat faster and harder, similar to when you exercise.
 The client’s blood pressure and heart rhythm (ecg) will be watched (monitored) the whole time.
 When the client’s heart is working as hard as it can, a radiopharmaceutical is again injected into one of their
veins.
 Let the client wait for 15 to 45 minutes.
 Again, the special camera will scan their heart and create pictures.
 The client may be allowed to get up from the table or chair and have a snack or drink
 Using a computer, the doctor can compare the first and second set of images. This can help the client’s doctor
tell if the client have heart disease or if their heart disease is becoming worse.
IMPLICATIONS OF ABNORMAL RESULTS:
 Cold spots on the scan, where no thallium shows up, indicate areas of the heart that are not getting an adequate
supply of blood. Cold spots appearing both at rest and during exercise may indicate areas where the heart
tissue has been damaged. However, "reversible" cold spots, appearing only during exercise, usually indicate
some blockage of the coronary arteries.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Identify the patient
 Inform the patient
 Inform accompanying persons and staff nursing a patient after a nuclear medicine examination or therapy
 Verify that the female patient is non-pregnant
 Ensure that a mother in lactation is given information about discontinuing nursing
 Perform the radiological procedure following an optimized protocol and ensuring patient protection
 Calculate administered activity to a child according to the local rules
 Verify the administered radiopharmaceutical and its activity
 Perform regular quality control of activity meter and gamma camera
 Contribute to the preparation of specifications for new equipment
 Participate in optimization of imaging protocols
 Inform the nuclear medicine physician and radiation protection officer (RPO) in the case of an accident or
incident.
S. TECHNETIUM
DEFINITION:
 Also known as myocardial infarct imaging, reveals the presence of myocardial perfusion and the extent of
myocardial infarction (MI). This procedure can distinguish new from old infarcts when a patient has had
abnormal electrocardiograms (ecgs) and cardiac enzymes have returned to normal.
PURPOSE:
 Is used to determine the occurrence, extent, and prognosis of myocardial infarction. Technetium-99m stannous
pyrophosphate is believed to combine with the calcium in damaged myocardial cells, forming a spot on the
scan
INDICATIONS:
 Aid in the diagnosis of (or confirm and locate) acute MI when ECG and enzyme testing do not provide a
diagnosis
 Aid in the diagnosis of perioperative MI
 Differentiate between a new and old infarction
 Evaluate possible reinfarction or extension of the infarct
 Obtain baseline information about infarction before cardiac surgery
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Patients who are pregnant or suspected of being pregnant, unless the potential benefits of a procedure using
radiation far outweigh the risk of radiation exposure to the fetus and mother
EQUIPMENTS:
 Collimator (All): Low energy, high resolution (LEHR)
 Non-gated imaging
 Energy window: 140 keV (20% window)
 Matrix: 128 x 128 - Pixel size: 3.5 – 6.5 mm
NORMAL VALUES:
PROCEDURE:
 Assess for history of hypersensitivity to radioactive dyes.
 Have emergency equipment readily available. This includes aminophylline to counteract the side effects of
dipyridamole if the dipyridamole test is to be performed.
 For scans conducted with stress testing, obtain a baseline 12-lead ECG.
 Fast for 4 hours before the test. Implication of Abnormal Result:
 MI, indicated by increased PYP uptake in the myocardium
IMPLICATIONS OF ABNORMAL RESULTS:
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen
Collection. Positively identify the patient.
 Ensure that the patient has complied with dietary and medication restrictions and other pretesting preparations.
 Ensure that the patient has removed all external metallic objects prior to the procedure.
 Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
 Have emergency equipment readily available.
 Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings
provided.
 Record baseline vital signs and assess neurological status. Protocols may vary among facilities.
 Establish an IV fluid line for the injection of saline, anesthetics, sedatives, radionuclides, or emergency
medications.
 Instruct the patient to cooperate fully and to follow directions. Instruct the patient to lie very still during the
procedure because movement will produce unclear images.
 Place the patient in a supine position on a flat table with foam wedges to help maintain position and
immobilization.
 IV radionuclide is administered. The heart is scanned 2 to 4 hr after injection in various positions. In most
circumstances, however, SPECT is done so that the heart can be viewed from multiple angles and planes.
 Monitor the patient for complications related to the procedure (e.g., allergic reaction, anaphylaxis,
bronchospasm).
 Remove the needle or catheter and apply a pressure dressing over the puncture site.
 Observe/assess the needle/catheter insertion site for bleeding, inflammation, or hematoma formation.
T. PHONOGRAPHY
DEFINITION:
 A pictorial recording of the cardiac sounds heard on auscultation.
PURPOSE:
 Aids diagnosis of cardiac valve abnormalities, hypertrophic cardiomyopathy, and left ventricular failure. May
be performed and retained for reference as part of the client’s permanent record as a visual representation of
the intensity and loudness of murmurs and other abnormal heart sounds. Excellent teaching tool because it
allows the learner to visualize the different heart sounds.
INDICATIONS:
 Locates and times abnormal heart sounds
 Evaluates left ventricular function
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Failure to obtain secure electrode placement causes an artifact in the electrocardiographic recording.
 Careful calibration is needed for the results to be diagnostic and generalizable.
EQUIPMENTS:
PATIENT PREPARATION:
 Obtain electrodes and alcohol.
 Clip the hair from the electrode sites before placement
 Fetal telemonitoring at home requires a mobile network and internet.
NORMAL VALUES:
PROCEDURE:
 The client is positioned supine. The electrode sites should be cleansed with alcohol and lightly scraped with
the edge of an electrode before placement.
 After the heart apex and base are located with a stethoscope, a microphone is strapped (or secured with suction
cups) in place over each site.
 Both an ECG and a PCG are recorded simultaneously for four complete cardiac cycles of sinus rhythm. For
dysrhythmias, 7 to 10 cardiac cycles are recorded. The procedure is repeated with the client changed to upright
and left-lateral oblique positions. The client may be asked to change his or her breathing patterns (that is, hold
breath or perform deep inspiration and expiration).
IMPLICATIONS OF ABNORMAL RESULTS:
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 Inform that a conductive gel is applied to the chest area
 Position the patient on his left side
 Remove the conductive gel from the patient’s skin.
 Inform the patient that the study will be interpreted by the physician
 Instruct patient to resume regular diet and activities.
U. MYOCARDIAL NUCLEAR PERFUSION IMAGING
DEFINITION:
 A non-invasive imaging test that shows how well blood flows through (perfuses) your heart muscle. It can
show areas of the heart muscle that aren’t getting enough blood flow.
PURPOSE:
 The nuclear stress test is most often performed to help diagnose whether coronary artery disease is the cause of
unexplained symptoms, especially episodes of chest pain or dyspnea. If coronary artery blockages are present,
this test can also help the doctor judge the severity of the blockages.
INDICATIONS:
 Inpatient Indications
 Chest pain evaluation - no known CAD
 Chest pain evaluation - known CAD
 Pre non cardiac surgery
 Post MI
 CHF/cardiomyopathy evaluation
 Arrhythmia evaluation
 Assess therapy for CAD
 Assess HR (chronotropic competence)
 Abnormal ECG
 Outpatient Indications
 Chest pain (equivalent) evaluation · Assess CAD risk (two or more risk factors)
 Pre non cardiac surgery
 Post MI
 CHF/cardiomyopathy evaluation
 Arrhythmia evaluation · pre exercise program
 Post cath assessment of ischemia · abnormal ECG
 Eval re Critical AS
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Uncontrolled heart failure heart attack within the past 2 days’ unstable angina
 Uncontrolled life-threatening cardiac arrhythmias
 Severe valvular heart disease
 Active endocarditis
 Cute aortic dissection
 Recent pulmonary embolus or deep vein thrombosis
EQUIPMENTS:
PATIENT PREPARATION:
 NO CAFFEINE 12 hours before your test!!! (NO coffee, tea, green tea, soda, chocolate, decaffeinated drinks,
migraine medication, or any other medication with caffeine)
 You must be FASTING except for water for 4 hours prior to the study. If you are diabetic, you may have a
light breakfast 2 hours before the stress test (Example: fruit, juice, & toast or cereal or oatmeal)
 NO SMOKING or CHEWING TOBACCO for 8 hours prior to the test Drink plenty of water before your test
Bring a heavy/high fat snack to eat after the test
 Please wear comfortable walking shoes. Ladies, please do not wear a dress
NORMAL VALUES:
PROCEDURE:
 During the first part of your test, a nuclear medicine technologist will place an IV into a vein in your arm or
hand and inject a small amount of cardiolite. Cardiolite is a radioactive tracer -- it is not a dye. It will be
necessary for you to wait approximately 30 minutes after the cardiolite injection to allow it to circulate.
 You will then be asked to lie very still on a special table under a camera (“gamma camera”) with your arms
over your head for about 12-15 minutes. The camera will record images that show the cardiologist how
efficiently blood is circulated through the coronary arteries to each area of the heart muscle at rest. • During the
second part of your test, a stress lab technician will prep ten small areas on your chest and place electrodes
(small, flat, sticky patches) on these areas. The electrodes are attached to an EKG monitor that charts your
heart's electrical activity during the test.
 You will lie on an exam table while the technician performs EKG’s and blood pressures while you are lying
down, sitting up and standing.
 Next, a medication called lexiscan is injected into your IV by a nurse, respiratory therapist or physician over
20 seconds while you are either walking very slowly on the treadmill or sitting on the side of the exam table
moving your legs in a walking motion
 A nurse, respiratory therapist or physician will flush your IV with saline immediately after injecting the
lexiscan. A small amount of cardiolite will be injected into your IV 10-20 seconds after your IV is flushed with
saline.
 Your blood pressure will be taken after the cardiolite is injected into your IV and every two minutes in
recovery.
 Please tell the technician immediately if you feel pain or discomfort in your chest, arm or jaw or if you feel
short of breath, dizzy, headache, lightheaded or if you have any other unusual symptoms at any time during the
test. The symptoms will go away typically within 3-4 minutes after the lexiscan injection. • Your heart rate,
EKG, and blood pressure are monitored throughout the test. The stress lab personnel will watch for any
changes on the EKG monitor that suggest the test should be stopped. A physician is available if needed.
 When the lexiscan portion of the test is completed, your IV will be taken out. You will wait for approximately
30-60 minutes after the cardiolite injection to allow it to circulate, then you will be asked to again lie very still
under the camera with your arms over your head for about 12-15 minutes. The camera will record images that
show the cardiologist how well blood circulates through the coronary arteries to each area of the heart muscle
during cardiac stress. If a part of the heart muscle doesn’t receive a normal blood supply, less than a normal
amount of cardiolite will be in those heart muscle cells
IMPLICATIONS OF ABNORMAL RESULTS:
 Low blood flow during rest and exercise. Part of your heart isn't getting enough blood at all times, which could
be due to severe coronary artery disease or a previous heart attack.
 Lack of radioactive dye in parts of your heart. Areas of your heart that don't show the radioactive dye have
tissue damage from a heart attack.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 The nurse instructs the patient to avoid caffeine (coffee, tea, and medications such as Anacin or Excedrin) for
24 hours prior to his test and to fast six hours beforehand. Small sips of water are OK.
 Before the test, the nurse attaches a blood pressure cuff to the patient’s arm, starts an intravenous line in his
other arm to infuse the adenosine, and applies electrodes on his chest to monitor his heart.
 The nurse checks blood pressure, heart rate and rhythm, and monitors for possible side effects such as chest
pain or breathing difficulties during the adenosine infusion.
 The nurse informs the patient that he can resume normal activities after the test. His physician will review test
results with him at a later date.
V. LYMPHOGRAPHY
DEFINITION:
 A potent hallucinogen derived from ergot, a fungus that spoils rye grain. It is equally effective by the
intravenous route as by the oral route, is metabolized in the liver and excreted in the bile, and affects both
parasympathetic and sympathetic nervous systems. May produce hallucinations years after ingestion, without
warning.
PURPOSE:
 To see whether the cancer has spread to other parts of your body.
INDICATIONS:
 Its main indications are for lymphoma (hodgkin's disease and non-hodgkin’s lymphoma)
 The study of pelvic lymph nodes (particularly from cervix uteri).
 Tomodensitometry has largely reduced the real indications of pedal lymphography.
CONTRAINDICATIONS/PRECAUTIONS & INTERFERRING FACTORS:
 Levels may be decreased if stored at room temperature.
 The use of Stealth adulterant in the urine sample will cause negative results in a positive sample.
EQUIPMENTS:
 Tube: Light-protected (usually amber), nonglass transport tube (for the blood and urine samples).
 Obtain a sterile specimen container (for the urine sample).
NORMAL VALUES:
PROCEDURE:
 Draw a 7-mL blood sample or obtain 4 mL of urine. Transfer specimen immediately to light-protected tube
IMPLICATIONS OF ABNORMAL RESULTS:
 Hypertension
 Tachycardia
 Piloerection
 Suicidal tendency.
 LSD related violent behavior includes suicide, homicide, and accidental death.
IMPORTANT NURSING RESPONSIBILITIES AFTER PROCEDURE:
 If the results are to be used as legal evidence, the chain of possession must remain unbroken from the time the
specimen is collected until court testimony.
 Refrigerate or freeze specimen until testing.
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 https://www.webmd.com/a-to-z-guides/lactic-acid-dehydrogenase-test
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